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\�J SAN 0.QUIN COUNTYPUSLIC HEALTH :RVICES <br />CNVIRONMENTAL HEALTH DiViSIvN r j� <br />304 EAST WESER AVENUE, THIRD FLOOR. <br />S A J STOCKTON CA 95202 �✓ <br />(209) 468-3420 <br />- PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANTS- K!CJ 1 'fL6UGkE:R— BUSINESSIAGENCY D( tLTG. �tJV tRC�>J►1 _N-[-gL� S�(T•iN7 <br />ADDRESSCAMP la,vE `2co ld <br />�IArP]rJCt0,W-4RW0 r <br />TENTATIVE* APPOENTtf1{EITDATE �- 1'$—d O TtMF- /0 -AM recce <br />(Please give 7 WIG buslnass days from darn of applicaiJon mittal) I 1111,1 <br />CHECK SOX TO EXPEDITE REQU T - $78.00 FLE - R UEST PROCESS[O IN 3 5USINESS BAYS <br />SIGNATURE OF APPLICANT DATE 6-Z-60 <br />e <br />i� UNDERGROUND TANK (UST) CLEANUP SrrE (LOP) O HOUSING ADATEMENT ❑ SCUD WASTE FACII-14UN 12 <br />0 OTHER CLEANUP SITE (NON -LOP) C2 FOOD FACILITY 13 SODU WASTE VEHICLE <br />UNOERGRCUND TANK (MON rfQWNGJREMOVAL) D DOG KF-NNEL 17 DAIRY <br />Q HAZARDOUS WASTE GENERATOR Cl CHICKEN RANCH ❑ PKG TREA ruENT PLANT <br />tD TIERED PERtBrrTED FACILITY G MOTEL)NOTEL 4 PUMPER TRUCKIYAR=HI_M TOILETS <br />t7 TATTOO/BODY PEIRCING M PCOL/SPA ❑ LAND USe APPLICAT)cu sITES <br />O MEDICA1. WASTE FACILITY Q PUBLIC WATER SYSTEM ❑ OTHER (PLEASE SPECIFY ASpV-=) <br />1 _ List up to ten addresses'in the space above. Select the typ0(s) of files frorn the list above by checking <br />the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-8138 or mail to the <br />5jddress indlGat9d above. <br />2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br />approximately five business clays but no later than ten (10) days after receipt of application. The files <br />Will be held for a maximurn of five business days for review. Appointments should be scheduled <br />accordingly. <br />3. A file that is actively being worked on by EHO staff may not be irnrnediately avallablo for review. A new <br />application may be submitted when the file i5 available. <br />4. Any file not returned in the same condition as released will be reorganized by END shaft at the expense <br />Of the applicant. Future file reviews by the same applicant may require a $78.00 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 />I <br />CONFIRMED APPOINTMENT DATE <br />I <br />DATE CONFIRMED <br />�EVIEWED YES NO <br />TIME <br />PHONE FAX <br />REVIEW DATE <br />IN ITIAL.S <br />TCITRL P.01 <br />