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06/14/2004 16:13 FAX 209 948062' Qj002 <br />—jDh*TE RECEIVED <br />— SAN JOAQUIN COUNTY <br />�) h� �'� ��_ �{ <br />�� �, ,� � ,�, • ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E Weber Ave 3 rdFloor Stockton, CA 95205 <br />.JUN 1 4 20Q�09) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd <br />ENVIRUNNIENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br />APP <br />L.K:ANT: aI✓ ll-�PctlU BUSiNESSlAGENCY: <br />ADDRESS: <br />PHONE: DSO / p % �S� ( FACSIMILE: <br />TENTATIVE' APPOINTMENT DATE: /�? 0 3 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 611K 03 <br />Department Use Onty <br />UNIT <br />❑ Unit 1 <br />Unit 3 <br />Unit 4 <br />❑ Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES �• x ,.r P - . <br />�- UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT K SOLID WASTE VEHIFAGICLE <br />❑ FOOD FACILITY <br />,1M <br />WASTE VEHICLE <br />,6. OTHER CLEANUP SITE (NON -LOP) ❑ DOG KENNEL ❑ DAIRY <br />UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br />HAZARDOUS WASTE GENERATOR ❑ MOTELAHOTEL ❑ PUMPER TRUGK/YARDtCHEM TOILETS <br />❑ TIERED PERMITTED FACILITY ❑ LAND USE APPLICATION SITES <br />13O <br />TATTOO/BOY PIERCING ❑ P <br />11 MEDICAL WASTE FACILITY ElOOTHER THER (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 wormed 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 />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 />E <br />CONF�EMED AP <br />POINTMENTDATE TIM <br />PATE: NIE[) <br />PHONE FAX <br />'ONFIRixNlTlA1-S �' <br />ktVIEWED YES NO REVIEW DATE <br />r QLDElio 48-02-006 - <br />M 2001 <br />