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DATE RECFWEQ LHD LOG NUMDF-Pt <br /> %NW SAN JOAQUTN COUNTS' ..,./ <br /> ENVIRONMENTAL MAL'TH DEPARTMENT <br /> ENT <br /> 304 E Wobe>;Ave 3'�Floor Stockton,CA 95205 <br /> (209)468-3420 Fax: (209) 464-0138 Web: www.co,san-Joaquin.ra.us/ehd Z3523 <br /> k'UBEzC RECORDS RELEASE APPLICATION <br /> APPLICANT 13USINE531AGENCY: <br /> PHONE_ 014 _I �,.—7 :0 FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: A3 Me Time. � <br /> (Please allow 10 business days from date of application submittal) <br /> XC14PC <br /> <BOX TO EXPEDITE R UE T-$93.00 F �REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT - DATE „01 <br /> Dep ent Use only <br /> il-S ADDRESS IT <br /> chy <br /> CI <br /> _ <br /> a. 5srcoi `i 3` cit 1 [ UnJ 2 <br /> v city <br /> 4. 5Veei � <br /> 1 <br /> Unlt 3 <br /> 6. 5trecit � h; <br /> r. 5srevs I Unit 4 <br /> e. s� <br /> 9. asset p Unit 5 <br /> �rt <br /> 10, Sired <br /> ENVIRONMEN �=Ai'MENTFILES <br /> X UNDERGROUND TANK(UST)CLEANUP SrtE(LOP) 01Ot1i ABATE MtNT O SOLID WASTE FACILITY <br /> eS OTHER CLEANUP SITE(NON-LOP) 0 FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> I k UNDERGROUND TANK(MONrroRiNGfREMOVAL) © DOG KENNEL 13 DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH 17 PKG TREATMENT PLANT <br /> TIERED PERMn31=1a fAGILTi'C ❑ MOTEL/HOTEL i] PUMPER TRUCKIYARDICHEM TOILETS <br /> 1D TIERED PERMITTED <br /> ODY PIERCING Q POOLISPA 0 LAND USI~APPLICATION SITES <br /> M MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> 1. List up to ten addresses in the space above. Select the type(s) of files from the list above try checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to 2091454-0138 or mail to the <br /> address indicated above. <br /> 2. EHD will notify the applicant if any EHD fires 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 field for a maXlmUrn 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 EHI]staff at the expense <br /> of tyle applicant. Future file reviews by the satire 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 RirViEW BATE <br /> EMp dd.4240g , <br /> aranaaa ' <br />