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Dec-09-05 10:08A ADR evivonmental Group 916 W 6688 P.01 <br /> END LOG NUMBER <br /> DATE RECEIVED SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT A I /�G O <br /> Il J 304 E Weber Ave 37d Moor Stockton,CA 95205 L <br /> Lint, _ (q*08-3420 Fax: (209)464-0138 Web: WWW.00.san-joaquin.ca.uS/ehd <br /> VIRON v'Ici`J`I NPALVIUBLIC RECORDS RELEASE APPLICATION <br /> P E °t <br /> APPLICANT: BUSINESSIAGENCY: <br /> ADDRESS: ) <br /> PHONE: RACSIM LE= I " �• <br /> TENTATIVE"APPOINYMENT DATE: )2 1 ki IdJ Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REOsT.$97.00 F E-REQUEST PROCESSED IN 3 BUSINESS DAYS p <br /> SIGNATURE OF APPLICANT <br /> I(i . QDATE <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> sin ❑ Unit 1 C <br /> an v 7 <br /> S. atnnr _^ JAY' <br /> je Unit 2 \(vy� <br /> A. SVeel aI \�M <br /> s. seen an Unit 3 <br /> a. Svn� a <br /> r svM u Unit 4 <br /> e. SVM on <br /> s. seen e O Unit 5 <br /> m. Sint <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 HOUSING ABATEMENT 0 SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) <br /> O FOOD FACILITY 0 SOLID WASTE VEHICLE <br /> O ❑ DOG KENNEL O DAIRY <br /> UNDERGROUND TANK ORINGlREMOVAL) 0 CHICKEN RANCH 13PKG TREATMENT PLANT <br /> HAZARDOUS WASTE GENERATOR 0 MOTEUHOTEL X PUMPER TRUCK/YARoiCHEM TOILETS <br /> 0 TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SUES <br /> 0 TATT001BODY PIERCING ❑ OTHER(PLEASE SPECIFY) <br /> ❑ MEDICAL WASTE FACILITY <br /> 1, List up to ten addresses in the space above. Sel Se selected-thsFax tsfr m the <br /> list above38 ob ail to the <br /> the appropriate box(es). At least one file type <br /> addressindlcated above. <br /> 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> approximately five business days but no later than ton(10) days after receipt of application. The files <br /> will be held for a maximum of five business days for review. Appointments should be scheduled <br /> accordingly. <br /> 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A now <br /> application may be submitted when the file is available. <br /> 4. Any file not returned in the same condition as releasedrrergEHD <br /> o t prior to review. <br /> of the applicant. Future file reviews by the same applicant May quire a$93.00 dep <br /> 6, 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications received after 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> �pumoes <br /> en,:eoe <br />