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UHO C KCI.CIVCV SAN JOAQUIN COUNTY <br /> u ENVI_ _ ENTAL HEALTH DEPARTM .. a- <br /> 304 E Weber Ave 3`d Floor Stockton,CA 95205Ar IN Ar Ar <br /> (209)468-3420 Fax: (209)464-0138 Web:www.cosan joaquin.ca.us/ehd AF ff <br /> PUBLIC RECORDS RELEASE APPLICATION 7qj <br /> APP (kJGc1 (1117 ,� T �' �� BUSINESSIAGENCY: <br /> �/ <br /> ADDRESS: / 12"Ar ca C'{- C 1 rGL Liye'lIVcr 'a- <br /> PHONE: <br /> PHONE: Zq— �(f 3� 11_V 0 FACSIMILE: <br /> w <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> An <br /> (Please allow 10 business days from date of application subm' <br /> !s <br /> CHECK BOX TO EXPEDITE REQUEST-$9 • EE-REQUEST PR SSED IN 3 BUSINESS DAYS / f <br /> SIGNATURE OF APPLICANT DATE <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> 1. S&ed S' S u�v 7�z C-6. -S?�C(C f <br /> - ❑ Unit 1 <br /> 2. Street City <br /> 3. Street citir <br /> ❑ Unit 2 <br /> 4. saed (� <br /> S. S CXY rUnidt <br /> �. <br /> 6. steel CRY <br /> T. sbeee <br /> 6. steel <br /> C 11 Ell <br /> e. west ❑ Unit 5 <br /> to. sem - <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> tor OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE "P <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELMOTEL ❑ PUMPER TRUCK/YARDICHEM TOILE+ <br /> ❑ TATTOOIBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> 1. List up to ten addresses in the space above. Select the type(s)of files from the list aboye 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 /> address 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 days for review. Appointments should be scheduled <br /> accordingly. . <br /> 3. A file that is actively being worked on by END 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 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 /> S. *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 /> 4ClJNF1,RMED"APP®INTMENTDAT 8 TIME <br /> DATE CONF.IRMEU. :PHONE : FAX : ' 1NIT4S <br /> fREV1EyVED YES NO REVIEW DATE <br /> EK0 48-02-006 <br /> WUM3 <br />