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�:ct��Lcr,r�uvu�u <br /> J SAN JOA# COUNTYPUBLIC HEALTH SERVI& <br /> �NNNAONMENTAL HEALTH DIVISION <br /> 04 EAST WEBER AVENUE,THIRD FLOOR <br /> STOCKTON CA 95202 <br /> (209)468,3420 <br /> PUSLIP.RECORDS RELEASE APPLICATION <br /> JEAN EN ? <br /> Y►pr'LIcaNT � <br /> C�,i�_ SIJSINlwSS1AGENGY SEc12� Ir.I.��ly Ana t�i�L <br /> ADDRESS I2-03LI 13401" 0,guxf 146 -{ �w�e lag R n1V- d WA .29057- <br /> PHONE 1425 - 3-m- i(op0 FACSIMILE kr Q �. <br /> TENTATIVE*APPOWTmENT�ATE 5 f o l TIS - 3'ao p ° �^�� _ <br /> (PWAXO dive 7 to 10 business days from data of npp&c;ktivn sulwrAttal) <br /> 6/v/ "* <br /> TS 3� Y <br /> ciiEc BOX TO ExPED116 REQUEST-$07.00 FEE-REQUEST PROCESSED 1N 3 BUSINESS DAYS <br /> , <br /> SIGKATURE OF APPLICANT DATE <br /> � <br /> s/22�j t <br /> FILEbD <br /> ARE s THIS SIDE END STAFF USE ONLY <br /> PROGRAM ELEMENTS SEARCH <br /> - <br /> rl <br /> • O <br /> D - <br /> J tU Lq <br /> ENVIRONMENTAL HEALTH DIVISION FILES s>\ <br /> w'utaOEPj3Aou?io TANK(usT)q,LJEANUP SITE(LOP) 0 HOUSINPi ABATEMENT 13 50L[O WASTE FACILITY <br /> W OTHER CLEANUP SITE,(NON-LOF) • , C] FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> W'UNDERGROUHD TANK(MONITORING/RdMOVAL) 0 DOG KENNEL C3 OAIRY <br /> 4KNAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH 0 PKG TREATMMaNT PLANT <br /> ae-nERED PERMITTED FACILITY 0 MOTEt1HOTEL 0 PUMPER TRUCKIYARD1CH9M TOILETS <br /> 0 TATTOOIRODY PEIRCING 0 PCAOIISPA .. - O LAND USE APPLICATION SrrES <br /> i3 MEDICAL.WASTE FACILITY '❑ PUBLIC WATER SYSTEM C7 OTHER(PLEASE SPECIFY ABOVE) <br /> 7, List up to ton addresses hi the space above_ Select the type(S)of files from the list above by checking <br /> the appropriate box(es). At Boast one file type MUST be selected, Fax to(209)464-01I 8 or mail to tha <br /> address lVdicatesi 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. AppointriTents should be scheduled <br /> accordingly. • <br /> 3. A Filo that Is actively beingi worked an by J-HD staff may not be immediately available for review. A new . <br /> application may be subtni4ed when the file is available. <br /> 4. Any file not returned in the same candition as released will be reorganized by EMD staff at the expense <br /> of the applicant. Future filia revlewe by the sitme applicant may require a$87.00 deposit prior to review, <br /> 5: 'TENTATIVE appointment,dates must be confirmed with EHD staff. <br /> s. Applications received after 3:90 pm will be peacessed the next business day_ <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES 'NO REVIEW DATE <br /> Of so u O=Ttw <br /> TOTAL P.01 <br />