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APPUCANT <br />ADDRESS <br />PHONJ� —4 <br />SAN J . UIN COUNTYPUBLIC'HEALTH S ICES <br />iRQNiVfEAITAI_ HEALTH DMS <br />304 EAST WEBER AVT ---NUE, THIRD FLOOR <br />STOCKTON CA 95202 <br />(209) 468-3420 <br />PUBLIC RECORDS RELEASE APPLICATION <br />RUSMESSIAGENGY <br />TENTATIVE` APPOIWMF-NT DATE _ TIME <br />(Pie"e give 7 to 10 business days from date of application submittal) d� <br />CHECK BOX TO EXPeDrFt Rr%QUEST - 7 , D E — GlUEST PR4CESSSp IN 3 BUSINESS DAYS i r i., _ S <br />�! 1 , <br />SIGNATURE OF APPLICANT I�AT1; t"(lLZ � z:00 <br />I/— <br />Q is kMOLA&ll>Z ,al go, 1.23 .1Ys'1 .2-26. _ �3 <br />Z SI <br />Y 1, ]cam \A I t,.,,44vl AAA rr <br />29oi, 4R9d--,It <br />ENVIRONMENTAL HEALTH DIVISION FILES lJtJlMil1 <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT 0 SOLID WASTE FACILnY J U N <br />QTHER CLEANUP SITE (NON -LOP) 0 FOOD FACILITY Q SOLID WASTE VV_1110LE <br />UNDERIaROUND TANS (IliONITORINGIREMOVAL) ❑ DOta KENNEL ❑ DAIRY <br />HAZARDOUS WASTE GENF-RA-rQR C3 CHICKEN RANCH 0 PKG TREATMENT PLANT <br />D TIERED PE KMITTED FAGIUTY ❑ MOTELIHOTEL 0 PUMPER TRUCKIYARDICHEIMI TOtLl rSS <br />❑ TAT 001BODY PEIRCING CI POOUSPA 0 LAND USE APPLICATION SITES <br />C3 MEDICAL WASTE FACILITY 0 PUBLIC WATER SYSTFU 0 OTHER (PLEASE SP5C(Fy ABOVE) <br />1. Dist up to ten addresses in the space above. Select the type(s) of files from the list above by checking <br />the approprlata box(es). At least one file type MUST be selactod. Fax to (209) 464-0135 or m_ aiI_to the <br />44gdror s indicated 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 ten (10) days after receipt of application. The files <br />will be held for a maximum of five business clays 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 />applicaltion may be submitted when the file is available. <br />.4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense <br />of the applicant. Future'fiie reviews .by the same applicant may require a $78.00 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 />COt4PIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX INITIALS <br />REVIEWED YES NO REVIEW DATE <br />