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uni Q rxm%,c,vcu <br />r=� , -SAN JOAQUIN COUNTY - <br />�► _�9 ► - IJ ENv6bNTNmNTAL HEALTH DEPARTaw <br />APR 0 6 304 E Weber Ave 3`d Floor Stockton, CA 95205 <br />266) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.,us/ehd <br />EVViR `1 i HEALTH <br />PERJIT/SERVICEPUBLIC RECORDS RELEASE APPLICATION <br />1", BUSINESS/AGENCY: ATC A <br />APPLICANT: J.,,,,,yh er '' Stoc.�-, c:r <br />ADDRESS: 1117 Loma. P-4,Ave Sy.4cB , %1,4540 , CA <br />PHONE: Zo9 - r-79-2221 FACSIMILE: <br />TENTATIVE* APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application sub <br />CHECK BOX TO EXPEDITE REQUEST - $93.00 FEE — REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT �� DATE <- <br />Department Use Only <br />UNIT <br />T. Street 5503 S. 4j!!:$or� 4J." cityS� �WV Unit 4 <br />as$}sveet ��6g 11G S. A4Tr a s `✓.,. P\� wr av t4 1 T,kI . <br />4. 5 Street 709 S - id 0�! V. �1 city5,� J4,a . ❑ Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES aft <br />�+. UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />)-SOLID WASTE_FACICITY <br />FILE ADDRESS <br />OTHER CLEANUP SITE (NON -LOP) <br />UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ FOOD FACILITY <br />❑ DOG KENNEL <br />❑ SOLID WASTE VEHICLE <br />❑ DAIRY.: <br />Street <br />Y9�i <br />$606 <br />e✓ ova" <br />S. /�i✓ <br />W <br />o <br />S o k o" nn <br />si-ocX�.a <br />Unit 1 <br />U P <br />street <br />Street <br />6110 <br />or <br />S. 41tr ot- <br />„ <br />Wa <br />o <br />cl029, <br />5 oe�t <br />Unit 2 <br />street <br />6122 <br />5.477 o <br />W <br />cityS <br />r o <br />S <br />Street <br />Y020 <br />$ . ; v <br />W <br />C <br />Slat <br />2 ? <br />c,ar <br />7ix7n <br />T. Street 5503 S. 4j!!:$or� 4J." cityS� �WV Unit 4 <br />as$}sveet ��6g 11G S. A4Tr a s `✓.,. P\� wr av t4 1 T,kI . <br />4. 5 Street 709 S - id 0�! V. �1 city5,� J4,a . ❑ Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES aft <br />�+. UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />)-SOLID WASTE_FACICITY <br />OTHER CLEANUP SITE (NON -LOP) <br />UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ FOOD FACILITY <br />❑ DOG KENNEL <br />❑ SOLID WASTE VEHICLE <br />❑ DAIRY.: <br />r <br />- <br />HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ PKG TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY <br />❑ MOTEL/HOTEL <br />❑ PUMPER TRUCK/YARD/CHEM TOILETS <br />TATTOOIBODY PIERCING <br />❑ POOUSPA <br />❑ LAND USE APPLICATION SITES <br />MEDICAL WASTE FACILITY <br />❑ 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 day. <br />CONFIRMED APPOINTMENT DATE TIMEXr <br />DATE CONFIRMED PHONE FAX. =INITIALS -'- <br />REVIEWED - YES NO REVIEW DATE <br />WMO03 <br />