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10/OIJ2004i'19:17 20946,3"l 8 AGE STOCKTON <br />PAGE 01/0 <br />EHO LOG NUMBER <br />E SAN JOAQUIN COUNTY <br />I� `I LU) E+ NviRoNMEN)<',AL HEALTH DEPARTKENT r <br />0 C T 0 20 304 E Weber Ave Yd <br />Floor Stockton, CA 95205 <br />9) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.cams/chd <br />'0 <br />ENVIRONMEW riEALTH PUBLIC RECORDS RELEASE APPLICATION <br />PF h VI �y} <br />APPLICANT: it SINESSIAGENCY: <br />ADDRESS: <br />PHONE:d'► ®% r 7� _/ `��a LJ (P FACSIMii-E: <br />- - yr <br />TENTATIVE" APPOINTMENT DATE: Time:&-,, <br />pdtJ <br />(Please allow IQ business days from date of apPilcatlon yubfflMal) O J <br />CHECK 80X <br />TO EXPEDITE REQ T • Ss .00 FEE.- REQUEST iROCESSED IN 3 BUSINESS PAYS ,/ <br />_9Pif 1A - / , - - . 114 <br />G, <br />milk" Fff; lard 0 -kit <br />Z_ rA61fth <br />Department Use Only <br />UNiT <br />❑ Unit 1 <br />❑ Unit 2 <br />0,01 nI <br />unit 4 <br />❑ Unit 5 <br />• <br />ENVIRONMENTAL DEPARTMENT FILEStY <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLiD WASTE FACT <br />gWW <br />OTHi;R CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY Q SOLID WASTE VEHICLE <br />UNDERGROUND TANK (MONITORINGiREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br />HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH E7 PK4 TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY ® MOTEUHOTEL 0 PUMPER TRUCKiYARDiCHEM TOILETS <br />13 TATTOOIBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br />O MEDICAL WASTE FACILITY [7 OTHER (PLEASE SPECIFY) <br />1. List up to ten addresses in the space above. Select 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 to (209)464-0138 or mail to the <br />a <br />. dclms Indicated above. <br />2. EHD will notify the applicant if any EHQ files exist. An appointment for review will be confirmed <br />approximately five business days but no later 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 may be Submitted when the file is available. <br />4. Any file not returned in the same condition as released will be reorganized by END 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 />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 />ON IRMEE) APPOINT'MEN -DATE TiMe <br />DATE EONFIRMEO' ..:PHONE FARC' .INITIALS <br />'REVIEWED • YES' " "'NQ RE1laEW MATE <br />R"D 4642-M <br />8MN93 <br />