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r <br /> SAN AQUIN COUNTYPUBLIC HEALTH WCES <br /> NV <br /> IRONMENTAL HEALTH DIVISIM UC1 U 1 <br /> �p tST WEBER AVENUE.THIRD FLOOR <br /> H' F �'�.� , . STOCKTON CA 95202 <br /> (209)468-3420 <br /> FEB 2131)"IC RECORDS RELEASE APPLICATION <br /> '4 <br /> LTH BuslNl;5SfAGENCY 1 <br /> APPLICANT <br /> ADDRESS � <br /> I <br /> PHONE FACSIMILE <br /> - - <br /> TIME <br /> TENTATIVE"APPOINTMENT DATE <br /> ' <br /> {Please Ulve 7 to 7a business days lrom date at appticatian submlltdq <br /> MCHECK Box TO EXPEDITE REQUEST•$78.00 FEF--REQUEST PROCE EQ IN 3 BUSINESS DAYS <br /> DATElid <br /> �tZl <br /> SIGNATURE OF APPLiCANT <br /> ,ry <br /> FLLE ADDRESS <br /> .3 <br /> 11V l <br /> O 1 L <br /> i <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> /� a soup WASTE F�c1uY <br /> E <br /> Ri'UNDERGROUNDTANIK(usT)CLEANUP SITE(t.OP) 0 HOUSING ABATEMENT � BUD WASTE FAILL <br /> Q�HER CLEANUP SITE(NON-LOP) <br /> 1--3 FOOD FACILrrY p DAIRY <br /> UrUNDERGKOUNDTANK(MONITORINGIREMOVAL) 0 DOG KENNEL ❑ PKG TREATMENT PLANT <br /> G7 HAZARDOUS WASTE GENERATOR 0 CHICKEN RANC1i <br /> ❑ MOTEIJHOTEL C1 PUMPER T3TUCKl1fARL)IGWEMTOILETS <br /> a TIERED PERMIT rLU FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITE'S <br /> 0 TATTOOBODY PEIRCING p PUBLIC WATER SYSTEM! Cl OTHER(PLEASE SPECIFY ABOVE) <br /> E3 10DICAL WASTE FACRIN <br /> Iov'e b checking <br /> List up to',ten addresses in the space above. Select the type(s)of tiles from the nisi ab y <br /> the appropriate box(es). At least one file type MUST be selected. Fax 209 46A-0938 nr m U-0-ftY <br /> address indicat above <br /> 2. EHD wilt 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(90) days after receipt of application. The files <br /> will be held for a maximum of five business days for review. Appointments should be sChedufact <br /> accordingly. <br /> 3. A file that is actively being wonted on by EHD staff may not be immediately available for review• Anew <br /> application may be submitted when the file is available. <br /> 4. Any file not returned in the earns 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$76.00 deposit prior to review. <br /> :5. *TENTATIVE appointment dates must be confinned with EHD staff. <br /> 6. Applications received after 3.00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMEq PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> Eke W 14 0IMs <br />