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w SAN *QUIN COUNTYPUBLIC HEALTH &ICES <br /> y� ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,THIRD FLOOR <br /> �J STOCKTON CA 95202 <br /> (209)46R-3420 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> A0"CAN7�n�U4yJ:�/ BUSINES*lAGENCY � �• <br /> ADDRESS <br /> PHONE '�Q Q FACSIM�E / <br /> TENTATIVE"APPOINTMENT OATS TIME <br /> (Plaasu give 7 to io buslnaea days tram date of applk2Hwl xubmlUal) <br /> �111111_5 31 <br /> }� CHECK BOX TO EXPEDITE REQU 3711,00 PREQUEST PR *SED IN 3 DUSUNP33 DAYS <br /> SIGNATURE OF APPLICANT�� DATE <br /> FILE ADDRESS <br /> Z S <br /> Z ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUAD TANK(UST)CLEANUP 917E(LOP) ❑ HOUSING ABATEMENT 0 SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) O FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONI ORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑ MOTELMOTEL ❑ PUMPERTRUCKlYARD(CHEM TOILETS <br /> El TATTOOlBODY PFJRCING 13 FOOIISPA O LANG UBE APPLICATION SITES - <br /> ❑ MEDICAL WASTE FACILITY a PUBLIC WATER SYSTEM _ C1 OTHER PLEASE SPECIFY ABOVE) <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 (2091464-M34 or mail to th <br /> address indicated above, <br /> 2 EHD will notify the applicant if any EHD files exist, An appointment for review wilt 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$76.00 deposit prior to review_ <br /> 5, 'TENTATIVE appointment dates must be confirmed with EHD staff- <br /> 6. Applications rocalvod after 3:00 pm will be procassed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE C7 IRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> N MAW <br />