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DATE RECEIVED EHD LOG NUMBER <br />r}�\rF �'.011;l SAN.TOAQ TIN COUNTY <br />fir- <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />20� 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br />OC C 1 (209) 468-3420 Fax: (209) 464-0138 Web: wNvw.co.san-joaquin.ca.us/ehd <br />F}y�lir\J1Virir{}f t� '(��{ <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT:, rl� P-G�C c b BUSINESS/AGENCY: �� �'i'^ r`^ V ' S a 0 c. . <br />ADDRESS: q <br />PHONE: -3� ` FACSIMILE: 2609- <br />TENTATIVE* APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application submittal) <br />CHECK BOX TO EXPEDITE REQUEST - $93.00 FEE - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE ) b f 1 1 104 <br />Department Use Only <br />rlAVIP- 0- <br />r , ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />❑ Unit 1 <br />❑ Unit 2. <br />Unit 3 G� <br />.,o[ Unit 4 <br />,,,,_ _Unit 5 <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br />OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br />UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br />HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br />TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS <br />❑ TATTOOIBODY PIERCING ❑ POOLtSPA ❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY ❑ 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 held 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 r e <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 />CONFIRMED APPOINTMENT DATE TIMEU7111 7 <br />DATE CONFIRMED PHONE FAX'INITIALS <br />REVIEWED YES NO REVIEW DATE <br />EHD 48-02-006 <br />8/88003 <br />FILE ADDRESS <br />1. <br />street c 1 o-4 N, S c V o o\ S -t aty <br />L.o d I (P <br />j" <br />city <br />"T <br />I <br />street a <br />+-b G L't-� (r7Z <br />4. <br />Street C. m tt i' S /I at, <br />1G tz-"' <br />5. <br />Street rj l ci-j cityS <br />tz t Ln– N� <br />6. <br />Street l `-t`'D G C vv\$t yA-v-e A)raty <br />7. <br />Street 3 S' Z rte/-�sL� 1/� LES tv--e. /Jl' <br />S:i C_ tv--" AK <br />8. <br />Street 3 V'� S, -t" !" Il/`ef�J �a <br />Sr�'l 'S C I1ri'7 +1u— Z L <br />9. <br />,'1Tt'--� <br />,J a <br />Street t-i-�J } S {; 1-��7� S'� ./�-, <br />S+D G`lG'�if� <br />" 10. <br />,,� <br />Street Yy'�- I N • T n�'�U�'� f 1 " ` ' 0 <br />S l o- J, 3r-� <br />rlAVIP- 0- <br />r , ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />❑ Unit 1 <br />❑ Unit 2. <br />Unit 3 G� <br />.,o[ Unit 4 <br />,,,,_ _Unit 5 <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br />OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br />UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br />HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br />TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS <br />❑ TATTOOIBODY PIERCING ❑ POOLtSPA ❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY ❑ 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 held 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 r e <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 />CONFIRMED APPOINTMENT DATE TIMEU7111 7 <br />DATE CONFIRMED PHONE FAX'INITIALS <br />REVIEWED YES NO REVIEW DATE <br />EHD 48-02-006 <br />8/88003 <br />