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DATE RECEIVED f� <br /> rlti�` (� �' i if SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> J' <br /> _C' E RONMENTAL HEALTH DEPAR ENT <br /> SEP 1 2 20 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br /> 09)468-3420 Fax: (209)464-0138 Web: vry%w.co.sanjoaquin.ca.us/ehd <br /> ''iVVIRUNMENT HEALTH <br /> PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: V t ,� G-O 0" BUSINESS/AGENCY: C Cr ��<r ►`, <br /> ADDRESS:1 ! �ti.-,l� Ve S•r ., 5r&.T <br /> PHONE:-_ Q / 2-3 I Q S I S FACSIMILE: Z-D 9 Z 3 H 0530 <br /> TENTATIVE*APPOINTMENT DATE: Vt/i 5G/J T IK Time: <br /> El/'CHECK <br /> � (Please allow 10 business days from date of application submittal) <br /> El CHECK BOX TO EXPEDITE REQUEST--$93.00 FEE-REQUEST PROC SS <br /> ED IN 3 BUSINESS DAYS <br /> il <br /> SIGNATURE OF APPLICANT DATE <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> x 1. Street S C tP C( "/ Ci S-)-o q 1 -- <br /> 2. Street Z5 Z T r a ❑ Unit 1 <br /> �r 3. Street 2, Q C Ci �) <br /> I Street ( Qt-• v , ❑ nit 2 <br /> /� G, <br /> 5. Street Q cityG� <br /> Street E A2 <br /> 1." city (� <br /> Unit <br /> 7. Street Ci <br /> 8. Street Cit :[; �1d Unit 4 <br /> 9. Street ..5 G ^ ® Unit 5 <br /> 10. Street CI S E P L Lt i <br /> �� ENVIRONMENTAL HEALTH DEPARTMENT FILES RU, <br /> L IiNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> �'OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> D TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOO/BODY PIERCING ❑ POOL/SPA ❑ 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 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 /> 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 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 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 daLl!;y <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE . FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHD 48-02-006 //M� �j T /�y p /Y) n / /+ <br /> 8/8/2003 ( / 1 f / l i b t '1 1 a/s �O I t GW 1,/ <br /> V <br />