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S <br />END LOG NUMBER <br />DATE RECEIVED SAN JOAQLTIN COUNTY <br />APPLICANT: <br />ADDRESS: _ <br />PHONE: _ <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E Weber Ave 3rd Floor Stockton, CA 95205 <br />(209) 468-3420 Fax: (209) 464-0138 Web: w-ww.co.san-joaquin.caus/elid <br />PUBLIC RECORDS RELEASE APPLICATION <br />�,/ M `�4'v^ / <br />?0-sb If mto , S, <br />y68 -3/G5 <br />BUSINESS/AGENCY: <br />1, ("1 <br />FACSIMILE: <br />ry w S'1 � o -d&"'. ) <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 �- ova`/ <br />SIGNATURE OF APPLICANT DATE 7 <br />Department Use Only NkNIF <br />UNIT <br />❑ Unit 1 <br />if <br />❑ Unit 2 <br />VUnit <br />❑ Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />❑ SOLID WASTE FACILITY <br />❑ SOLID WASTE VEHICLE <br />TIER CLEANUP SITE (NON -LOP) <br />!9UNDERGROUND TANK (MONITORINGlREMOVAL) <br />❑ FOOD FACILITY <br />❑ DOG KENNEL <br />❑ DAIRY <br />❑ PKG TREATMENT PLANT <br />HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ MOTEUHOTEL <br />❑ PUMPER TRUCKIYARDICHEM TOILETS <br />❑ TIERED PERMITTED FACILITY <br />❑ POOUSPA <br />❑ LAND USE APPLICATION SITES <br />❑ TATTOO/BODY PIERCING <br />❑ MEDICAL WASTE FACILITY <br />❑ 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 (2091464-0138 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 - <br />TIME <br />DAE CONFIRMED.77 <br />TPHONE FAX INITIALS ': <br />REVIEWED YES NO REVIEW DATE. <br />eE M48-02-006 q- avj `610 ltazel(dr7 US+33©hf0 PA <br />