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DATE RECEIVED <br /> SAN JOAQUIN COUNTY <br /> NV �NMENTAL HEALTH DEPART4r <br /> J <br /> 0 304 t Weber Ave 3`d Floor Stockton, CA 95205 <br /> APR 0 6 20 <br /> 0209) 468-342Q Fag: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd <br /> C-NViRi.iPVVIE1'0 HLALI H <br /> PSP-'^IT/SER','iCES P LIC RECORDS RELEASE APPLICATION <br /> APPLICANT: S C H D ('t BUSINESSIAGENCY: <br /> ADDRESS: 3 SSS `1 a ^C it Zee <br /> PHONE: 6f4-- "- /p—g3 q FACSIMILE: <br /> ■ <br /> TENTATIVE' POINTMENT DATE: Time: r e-c ^,v <br /> i(Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE RE EST- 93 E–RE ESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT - DATE <br /> Department Use Only <br /> ,±"DRESS UNIT <br /> 1. Shed tRf�e- nit 1 <br /> i. stream ?OOU <br /> 3. SUeN City <br /> Unit 2 Iv <br /> 4. Street City 00w, <br /> s. street oty Unit 3 <br /> 6. strut <br /> 7. Strom lip Unit 4 <br /> 8. Street #= U L!=IV Tam <br /> 9. street C 212 9100A ❑ Unit 5 <br /> 10. Street oty �J <br /> 11 ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CL UP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> iOTHER CLEANUP SITE(NON-LO ) FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> O NOERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETJQ <br /> ❑ TATTOOIBODY PIERCING ❑ POOLtSPA LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FAC ❑ OTHER(PLEASE SPECIFY) <br /> 1. List I. to n al <br /> ses in the space above. Select the type(s)of files from the list above by checking <br /> the appropriate bo es). At least one file type MUST be selected. Fax to (209)464-0138 or mail to the <br /> address indicated a ove. <br /> 2. EHD will notify the pplicant if any EHD files exist An appointment for review will be confirmed <br /> approximat ly five usiness days but no later than ten (10)days after receipt of application. The files <br /> will be held fora m imum of five business days for review. Appointments should be scheduled <br /> according' . <br /> 3. A file that 1 active) being worked on by EHD staff may not be immediately available for review. A new <br /> application may be ubmitted when the file is available. <br /> 4. Any file not returne in the same condition as released will be reorganized by EHD staff at the expense <br /> of the applicant. F ture file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> 5. *TENTATIVE appoi tment dates must be confirmed with EHD staff. <br /> 6. Applicatio receiv d after 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTME TDATE TIME _ <br /> DATE CONFIRMEDPHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHO 4a-02-006 - - <br /> 6!8!2003 <br />