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DATE RECEIVED SAN JO'AQUIN COUNTY <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.ca.us/ehd <br />PUBLIC RECORDS RELEASE APPLICATION <br />tY of S'/ qo-.,fc ",-') <br />APPLICANT: <br />ADDRESS:_ <br />PHONE: — <br />I/U." 14V^_1 <br />?0,90 Y� M110 , S, <br />_ BUSIN//�QESSIAGENCY: <br />-J, 0I <br />TENTATIVE* APPOINTMENT DATE: <br />FACSIMILE: <br />Time: <br />(Please allow 10 business days from date of application submittal) <br />EHD LOG NUMBER <br />Im <br />® CHECK BOX TO EXPEDITE REQ U $9 . - REQUEST PROCESSED IN 3 BUSINESS DAYS 0-to7 <br />aC ( <br />SIGNATURE OF APPLICANT SATE <br />Department Use Only <br />UNIT ArWI <br />im <br />❑ Unit 1 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />❑ Unit 2 <br />® Unit <br />Unit 4 <br />❑ Unit 5 <br />13 HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br />. UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br />OTHER CLEANUP SITE (NON -LOP) 0 DOG KENNEL ❑ DAIRY <br />UNDERGROUND TANK (MONITORINGIREMOVAL) 0 CHICKEN RANCH ❑ PKG TREATMENT PLANT <br />0 HAZARDOUS WASTE GENERATOR ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br />TIERED PERMITTED FACILITY 0 p®OUSPAL ❑ LAND USE APPLICATION SITES <br />❑ TATTOO/BODY PIERCING 0 OTHER (PLEASE SPECIFY) <br />❑ MEDICAL WASTE FACILITY <br />1, List up to ten addresses in the space above. MUSTthe <br />be see cted f Faxfiles <br />to (209) 464-0138 or mail checking <br />the <br />the appropriate box(es). At least one file type <br />address indicated above. <br />2. END 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 />ked on by END staff may not be immediately available for review. Anew <br />3. A file that is actively being wor <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 END staff. <br />6. Applications received after 3:00 pm will be processed the next business day. <br />CONFIRMED' APPOINTMENT DATE TIME <br />PHONE FAX <br />"DATE CONFIRMED <br />INITIALS <br />REVIEWED -. YES NO <br />REVIEW DATE <br />E.04"2.006�_ D 6,0 I�aiel�e'j U5+33©! 4 f -CPA <br />818!2003 _ f <br />