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ATE RECEIVED EHD LOG NUMBER <br />SAN JOAQUIN COUNTY <br />- ENVIRONMENTAL HEALTH DEPARTMENT <br />OCT19;4-. <br />2 42 <br />QR09) <br />304 E Weber Ave 3d Floor Stockton, CA 95205 468-3420 Fax: (209) 464-0138 Web:.co.san joaquin.ca.usloh'd' <br />Li'V'Jli`!il'Ji:i=iv'; iEALTfi <br />;FS PUBLIC RECORDS RELEASE/ AAPPLICAI� _ <br />APPLICANT: I�/1 (_��L7 BBUUS`IN�ESS/AGENCY: CACI Y /!/N �JLfI� �ylt d"� <br />ADDRESS: j2j Q `�(Z �? o itic)S c. hi,) GI DS 6L:5 <br />PHONE:'J//?�GZS�CJ�� «ZO FACSIMILE: ,( <br />TENTATIVE* APPOINTMENT DATE: .C�` ZO 22Time:10AM <br />(Please allow 10 business days from date of application submittal) <br />CHECK BOX TO EXPEDITE REQST - 3 FE – REQUEST OCESSED IN 3 BUSINW�1Xj 03 <br />SIGNATURE OF APPLICANT7� DATED <br />Department Use Only <br />UNIT <br />❑ Unit 1 <br />nit 2 <br />ni <br />e <br />4 <br />❑ Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />i7 I INDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />FIL ADDRE S <br />OTHER CLEANUP SITE (NON -LOP) <br />1. <br />Street <br />G 8L <br />V <br />pg <br />cityQ. C <br />2. <br />Street <br />W. t <br />C-fERED PERMITTED FACILITY <br />CI <br />3. <br />Street <br />�' `. <br />'' AA <br />A C <br />Ci <br />4. <br />Street <br />.,Ci <br />5. <br />Street <br />1 ` • e. <br />I 0 ��® <br />L <br />CI <br />6. <br />Street <br />p� <br />LIG. 1 aKY <br />7. <br />8. <br />Street <br />Street <br />city <br />ci <br />9. <br />Street <br />CI <br />10, <br />Street <br />CI -1" <br />r" <br />UNIT <br />❑ Unit 1 <br />nit 2 <br />ni <br />e <br />4 <br />❑ Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />i7 I INDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />❑ SOLID WASTE FACILITY <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />❑ SOLID WASTE VEHICLE <br />QIUNDERGROUND TANK (MONITORINGIREMOVAL) <br />❑ DOG KENNEL <br />❑ DAIRY <br />INiAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ PKG TREATMENT PLANT <br />C-fERED PERMITTED FACILITY <br />❑ MOTEL/HOTEL <br />❑ PUMPER TRUCK/YARD/CHEM TOILETS <br />❑ TATTOOIBODY PIERCING <br />❑ POOLISPA <br />❑ LAND USE APPLICATION SITES <br />"EDICAL 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 TIME <br />DATE CONFIRMED PHONE FAX INITIALS <br />REVIEWED YES NO REVIEW DATE <br />EHO 48-02-006 <br />8/8/2003 <br />