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OG/03/2005 12:23 209522 —17 GEOLOGICAL TECF' ,S PAGE 01/0 <br /> EHD LOCA NUMBER <br /> DATE RECEIVED SAN JOAQUIN COUNTY <br /> ( , ] (� ENVIRONMENTAL REAL'ITII DEPARTMENT <br /> ���1���1 c 304 L Weber Ave P Floor Stockton, CA 95205 <br /> (D1E <br /> � u (209) 468--3420 Fax: (209)464-0138 Web:www.CQ,san joaquin.ca.us/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> ENV1R �r ;c <br /> � W c BUSINESSiAGENCY: �� <br /> ADDRESS: <br /> PHONE: (apCl ) FACSIWLE: <br /> TENTATIVE`APPOIN17AP-NT DATE: TlM°- <br /> (Plea oMOO <br /> 10�a�6� of appitcatlon submittal) <br /> 173 CHECK BOX TO EXPEDITE REQ EST• FEE-REQUEST ED IN 3 BU91NI*SS DAYS <br /> SIGNATURE OF APPLICANT v vim`— DATE 3 D <br /> DaparhTwrg Uas Only <br /> FILE ADDRESS UNIT <br /> a smea !�. PXWCUA AV2 ~�' >^i'r Unit 1 <br /> x. s,�� :Q�"r.. <br /> a spa �" ❑ MR 2 <br /> fn <br /> nit 3 <br /> a. sum <br /> y I Unit 4 <br /> ro� <br /> e 4 LOCA-A- Yvt� ;�ea ��nit5 <br /> B- Siroel <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(IAP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER aLFANvP SITE(NON-LOP) ❑ FOOD FACILITY M SOLID WASTE VE"CLE <br /> t2 UNDERGROUND TANK(MONITORINGIREMOVAL) 0 DOLS KENNEL O DAIRY <br /> 1,7j HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> 0 TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUWER TRUCKNAR=HEM,TOILETS <br /> ❑ TATTOOA300Y PIERCING ❑ POOLISPA ❑ LAkD 118E APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY la OTHER(PLEASE SPE�FY) <br /> 1. List up to ten addresses in the space above. sept the type(s)of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax 042,09)46"13§or OMII to the <br /> address indicated above. <br /> 2. EHD will notify the applicant if any EHD flies exist. An appointment for review will be confirmed <br /> approximately five business days but no latter than ten(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 new <br /> application nM be submitted when the file is available. <br /> 4. Any file not retumed In the same condition as released will be reorganized by EHD staff at the expense <br /> of the applicant. Future file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> 5, *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 /> RWA tb YES NO REVIEW DATE <br /> QlIA 1 <br /> aiatxoea <br />