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SAN JOAQUIN COUNTY IIII <br />DATE RECEIVED <br />ECF75:0 ENV1RONMENTAJL HEALTH DEPARTMENT <br />304 E Weber Ave 3rd Floor Stockton, CA 95205 <br />JUN 2$ 2006(209) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.cams/elld <br />ENVIRONMEN I HEALTH P IRK RECORDS RELEASE APPLICATION <br />Arpt_IcAn4T7-5Arr\A ).C45'6 BUSINESS/AGENCY: Np 1 1 0 se c\\_ 4177-550( <br />ADDRESS: r) P\) (AhA 1,0 4r4,_SD- 174 <br />PHONE: 63- 370J FACSIMILE: 3 6 <br />I.) P G 00 TENTATIVE* APPOINTMENT DATE: I <br />ease allow 10 busina claysffoni date of appli;:atior: submittal) <br />EHD LOG NUME ER <br />CHECK SOX TO EXPEDITE RE <br />SIGNATURE CIF APPLICANT <br />T $93.00 FEE EaUEST P ZSSED IN 3 BUSINESS DAYS <br />DATE <br />cportmt:nt l'se Only <br />FILE ADDRESS 0 . <br />- ,‘ . 011 4 - , Jk i\--i —r —i" , - T.s.c.A4 city <br />City <br />3. S;r2e1 <br />2. S's t\„...\.\ t <br />City <br />I. 5:r n,:•.1 Rb.AL p, <br />.T. sTmt '',Orte\ 'r r City <br />E. Strt•elt ' <br />.,.....1 ......." <br />Clly <br />7. VvItt <br />tK-u FrO ;s--(0-- <br />City <br />&Het UN <br />,, Slreet DI," '=-,............... <br />_lc, Srf-,•131 • <br />UNIT <br />0 unit <br />0 URI 2 <br />/ Unit 3 <br />/ Unit 4 <br />LII Unit 5 <br />ENVIRO <br />."..e.UNDERG i0UND TANK (UST) CLEANUP SITE (L HOUSING ABATEMENT In SOLID WASTE FACILITY <br />A OTHER CLEANUP SITE (NON-LOP) 0 FOOD FACILITY 0 SOLID WASTE VEHICLE <br />-A UNDERGROUND TANK (MONITORING/REMOVAL) 0 DOG KENNEL 0 DAIRY <br />7St HAZARDOUS WASTE GENERATOR O CHICKEN RANCH PKG TREATMENT PLANT <br />TIERED FERMITTED FACILITY MOTELJHOTEL 0 PUMPER TRUCK/YARD/CHEN. 'CC/4,El S <br />TATTOO/800Y PIERCINS o POOL/SPA 0 LAND USE APPLICATION SITES <br />0 MEDICAL WASTE FACILITY 0 OTHER (PLEASE SPECIFY) <br />List up to ten addresses in the space above. Select the type(s) of files from the list above kly checking <br />the appropriate box(es). At least one file type MUST be selected. Fax to (2091_4_64-0138 or m2il tO the <br />address indicated above, <br />El-ID 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 applicntion. The relies <br />wilt be held for a maximum of five business days for review. Appointments should be scheduled <br />accordingly. <br />A file that is actively being worked on by El-ID staff may not be immediately available for review. A new <br />application may be. submitted when the file is available. <br />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 rovie'6% <br />"TENTATIVE appointment dates must be confirmed with El-ID staff. <br />Applications received after 3:00 pm will be processed the next business day. <br />GONFIRIVIliD APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX INITIALS _ <br />REVIEWED .. YES NO REVIEW DATE <br />EHO a.o2.0Dr, <br />11/=003