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Mar -18=04 11:2.7A _ l <br />PRECEIVEU.. U s <br />L� I�'1'%/i�i1 SAN JOAQUINCO[rVTY <br />\ V ID ENVIRONMENTAL 11EALTH DEPARTMENT <br />MAR 1 82 qd 304 F Weber Ave T° Floor Stockton, CA 95205 <br />Q�09) 469 1;120 Fax: (209),t64-0138 Web: www.co.san ;joaquin.ca.us/chd <br />ENVIRUMVIEidl-HEALTH , <br />PFRMITlCGPUBLIC UBLIC RECORDS RELEASE APPLICATION <br />P o I <br />FHD I OC' NIJMB� <br />I#07 <br />37 <br />APPLICANT: 'URVU lO/lam/,^�,,�'f BUSINE/S�SIAGENCY: <br />ADDRESS: w CGS�7i._��rtIC. />•_/'j.!! C.(o-lfCA. <br />PHONE: �.J� ' l_O �_rTG�!__....__. FACSIIMjILLE:�.�.�.. <br />TENTATIVE` APPOINTMENT DATE: I f `�"-/ I/"` �"� 7 6W 1JTime: <br />(Please allow 10 bus days from date f application subminali <br />i <br />CHECK BOX TO EXPEDITE REgUEST - f93.00 qU ST�PR S$ED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE <br />uuarbl t Use Only <br />IT <br />Unit t <br />❑ Unit 2 <br />�Unit3 ���s <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />FILE ADDRESS <br />o U ",ROUND TANK (UST) CLEANUP SITE (LOP) <br />1. <br />$IrerY <br />/1 <br />'i. <br />I' <br />QIIM <br />T. W <br />GXv <br />3. <br />s..,i .. <br />5 t <br />k <br />All <br />-r f w <br />ci� � _.. .. .....: <br />❑ CHICKEN RANCH <br />u..a <br />❑ TIERED PERMITTED FACILITY <br />❑ MOTEUHOTEL <br />rn <br />.. <br />Cvam <br />O POOLISPA <br />❑ LAND USE APPLICATION SITES <br />Cu <br />s. <br />M1 <br />Syeel <br />9rgnf <br />City .... ..._. <br />r_li. <br />f 1 <br />10. <br />synd <br />- <br />Cx .•.. <br />uuarbl t Use Only <br />IT <br />Unit t <br />❑ Unit 2 <br />�Unit3 ���s <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />o U ",ROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />❑ SOLID WASTE �ACIlITY'^' <br />❑ HER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />❑ SOLID WASTE VEHICLE <br />11MiSERGROUND TANK(MONITORINGfREMOVAL) <br />❑ DOG KENNEL <br />❑ DAIRY <br />M"HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />PKG TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY <br />❑ MOTEUHOTEL <br />_❑ <br />❑ PUMPER TRUCKIYARDICHEM TOILETS <br />❑ TATTOO/BODY PIERCING - <br />O POOLISPA <br />❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY <br />❑ OTHER (PLEASE SPECIFY) <br />1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking <br />the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the <br />address indicated above. <br />2. EHD 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 application. The files <br />will be hold for a maximum 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 EHD staff at the expense <br />of the applicant. Future file reviews by the same applicant may require a $93.00 deposit prior to review. <br />S. "TENTATIVE appointment dates must be confirmed with EHD staff. <br />6. Applications received after 3:00 pm will be processed the next business day. 4 '' <br />Ell <br />APPOINTMENT DATE <br />DATECONFIRMED <br />REVIEWED YES NO <br />TIM E <br />PHONE FAX INITIALS <br />REVIEW DATE <br />