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kk <br />fERECEIVED EHD LOG NUMBER <br />ENPSAN JOAQUIN COUNTY <br />IRONMFNTAL HFALTH DEPART NT <br />304 E Weber Ave 3`d Floor Stockton, CA 95205 <br />(209) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd q6q <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: '� � i°� BUSINESSIAGENCY: e� ?y <br />ADDRESS: /F.090 V. <br />PHONE: 190-3/G0i <br />FACSIMILE: <br />TENTATIVE* APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application submittal) <br />® CHECK BOX TO EXPEDITE REQU $9 . — REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE <br />Department Use Only <br />UNIT <br />❑ Unit 1 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />❑ Unit 2 <br />"X PUnit <br />❑ Unit 5 <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) 13HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br />NER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br />UN <br />TDERGROUND TANK (MONITORING/REMOVAL) ❑DOG KENNEL L❑DAIRY <br />HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARD/CHEM TOILETS <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 types) 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 day. <br />CONFIRM ED.APF?OINTMENT.DATE TIME <br />DATE C01 FIRMED PHONE FAX- INITIALS <br />REVIEWED YES NO REVIEW DATE, <br />