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aep, 2. iHd IV: IIAM No. 2539 P. 1/2 <br /> DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> _ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 Last Main Street, Stockton, CA 95202-3029 <br /> �i!•�, ' 6) c�C'c Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjC)g <br /> gov.or /eh <br /> j�- PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: &MrI6' f 1 ( r: <br /> ADDRESS: IVlive, 6k 14f, <br /> e) City/Statelzip <br /> PHONE(1): -II 0 XLO, PHONE(2): FACSIMILE: 1S 3 '� <br /> TENTATIVE'APPOINTMENT DATE: Z2 t 2ODS Thne: a"1 <br /> (Please allow 10 business days from dat-hof applicatlon submittal-'Tentative only-must be confirmed) <br /> ID CHECK BOX TO EXPEDITE REQUEST-$105 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT �h�i�r//�fn �� L <br /> Electronic Informat <br /> -ID USE ONLY <br /> ❑ Unit 1 <br /> 2- UnIt2 <br /> 17 <br /> 3. <br /> 4. 665 Unit 3 <br /> 6 ` Unit4 <br /> 7. ---- <br /> a• - � � ❑ unit 5 <br /> 9. L ❑ Unit 6 <br /> 10. <br /> Specific Date Range of -O --- <br /> UNDERGROUND TANK(USS 1 " (/ �_ •ACILITYNEHICLE <br /> OTHER CLEANUP SITE(N( <br /> NDERGROUND TANK(MC <br /> --- <br /> AZARDOUS WASTE GENE TREATMENT PLANT <br /> TIERED PERMITTED FACILI _ --- ----- -- - ---- ]YARD/CHEM TOILETS <br /> 171 TATTOO/BODY PIERCING ]CATION SITES <br /> 173 MEDICAL WASTE FACILITY <br /> WELL AND SEF--- - ---- --- -- - - - - 'LUDING HOLIDAYS. <br /> 1. List up to ten addrw scking the appropriate <br /> box(es). At least on dicated above. Address <br /> ranges will not be ac plications received after <br /> 3:00 pm will be proc <br /> 2, The EHD will notify t ned approximately ten(10) <br /> days after receipt of _ - - -®view. Appointments <br /> should be schadulac - <br /> 3. A file that Is actively ----A new application may be <br /> submitted when the - - <br /> 4. Any file not returned In the same condition as released will be reorganized by EHD staff at the expense of the applicant- <br /> Future file reviews by the same applicant may require a$105 deposit prior to review. <br /> EHD USE ONLY <br /> EHD 4M6 8/04/08 PUBLIC RECORDS RELEASE APP FORM <br />