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X1003 <br /> iv,/28/2004 13:24 FAX 209 94 1 t�.,...�..•..••� <br /> DATE RECEIVED SAN d OAQUIN COUNT' � <br /> EN MONMENTAL HEALTH AEPARTMMNT <br /> 304 E Weber-Ave 3'd Floor Stockton,CA 95205 <br /> (209)468-3420 Fax: (209)464-0138 Web:wVrw.cosan joaquin.ca.us/ehd <br /> 4?000000' <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> AP :' SUSINESSIAGENGY: <br /> ADDRESS: <br /> PHONE: S�tg C3�lS FAGSIMII..E: 4 I tqqw- <br /> TENTATIVE*APPOINTMENT DATE: <br /> (Pfease allow'10 business days from date of application subtnRtal) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE—REQUEST ppOCESSED IN 3 6USMESS DAYS <br /> DATE <br /> SIGNATURE OF APPLICANT _ I� Department Use Orly <br /> UNIT <br /> FILE ADDRESS <br /> Unit 1 <br /> i Stireee z }on " '" - �'' Unit2 <br /> c, r <br /> 4, $�rcd ock� <br /> s, stens ' <br /> a. street 1 Unit <br /> T. Street <br /> a. Unit 5 <br /> 9. steed <br /> 10. $ ea <br /> ENVIRONMENTAL HEAI-TH DFpARTNIENT FILES <br /> SOLID WASTE FACILRY <br /> &14 UNDERGROUND TANK NST) 13 FOOD FACLfTY a$. DAIRY CLEANUP Sr E(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE VEHICLE <br /> IS OTHER CLEANUP SITE(NON-LbP) ❑ DOG KENNEL at PKG TREATMENT PLANT <br /> {A UNDERGROUND TANK(MONTTORINGIREMOVAL) r3CHICKEN RANCH p PUMPER TRUCK/YARD/CHr=iA TOILETS <br /> ja }HAZARDOUS WASTE GENERATOR ❑ MOTEVyOTEL <br /> [3 TIERED PERMfTTED FACILITY r3POOLISPA yk LAND USE APPLICATION SSS <br /> ❑ TATTOOMODY PIERCING ❑ OTHER(PLEASE SPECIFY) <br /> O MEDICAL WASTF.FACK-ITV checking <br /> List up to tent addresses typ <br /> in the space above. Select the (s)of files from the list above 4 <br /> the appropriate box(es). At least one file type MUSY be selected. Fax to z09 X64 0138 or m mail to the <br /> 1, <br /> address indicated above_ E}1D files exist An appointment for review will be confirmed <br /> 2. EHD lerili notify the applicant if any ( )days p plication, The files <br /> approximately fn►e business days but no later than ten je . after receipt <br /> should be scheduled <br /> Will be held for a maximum of five business days for review. Appointments <br /> accordingly. EHD staff may not be immediately available for revlew. Anew <br /> 3. A file that is actively being worked'on by • <br /> application may be submitted when the file is available. at the <br /> nSe <br /> a. Any file not returned in the same condition as released pnt maill be r rer$anized uire a$93 00 deposit prior tope view <br /> of the applicant. Future file reviews by the same applicant Y q <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 /> TIME <br /> CONT{.RM�p` ?poiErrrvATE �NrriAts ;r <br /> ;ti•.. <br /> _ PFIONE <br /> FAX', <br /> t,.. I <br /> DATE• CINFIRIkIED <br /> REVIEWED •YES <br /> 'NO REVIEW DATE•: <br /> • Ett01a-0Z.000 . <br /> IM2001 <br />