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SAN JOt�gUIN COUNTYPUSLIC HEALTH SL-&.VICESENVIROLam/ Rc <br /> ION <br /> 304 EAST WEBER WEBER AAVENUE THIRD FLOOR <br /> MENTAL HEALTH <br /> STOCKTON CA 95202 <br /> {209)468120 <br /> �A ( `PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT I�lari(41[.a, BUSINESSIAGENCY (-QVv4r I~o.r`t'y� ��cltir4o (ogjrZS, .'�C. <br /> ADDRESS J88 1=ro-v�lc 1e- i- Grr•�l¢ �-,� Z � �L�._.(-.6„� GA c'lsza <br /> PHONk Z-a9 - 2.5-4 - LISI S FACSIMILE 'Lfl`I — 23-4 _ C s-t s <br /> TENTATI E'APPOINTMENTDATE I1 $a $.POI TIME <br /> (Please"T to ttl 6 know days frau date of appiioa6on sa.binittap <br /> CHECK BOX TO FJXPF-0RE REQUEST-487.00 FEE—REgUES P 1 3 UUSINES9 DAYS <br /> SIGNATURE OF APPLICANT DATE lr try moo j <br /> FILEADDRESS THIS SIDE EHD STAFF USS ONLY <br /> PROGRAM ELEMENTS SEARCH O <br /> t S. A yw-&-v it w V% war <br /> 2 S• C.0. 1 <br /> 32 ArrAricar� <br /> V <br /> ✓3 0 8 Fl.t a �t Le r� NnV 21 n 1/ <br /> ENVIRONMEN'T'AL HEALTH DIVISION FILES <br /> t.'7 SINDFROROUND TANK(USAN SITE(LOP) r°I HOUSING ABATEMENT 0 SOLID WASTE FAgLITY <br /> 7�l=ER CLEANUP SITE(NON4.OP) t9'rFOOD FACILITY P SOLID WASTE VEHICLE <br /> 5 NDER43ROUND TANK(MONITORINGIREMOVAI..) _ ❑ DOG KENNEL M DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELRIOTFJ.. t7 PUMPER TRUCK1YAmcHEM TOtLETs <br /> 0 JA TTOO1B0OY PEIRCIIG 0 POOLJSPA UAN <br /> LD USE APPLICATION SITES <br /> t�MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM CJ OTHER(PI_FASE SPECIFY ABOVE) <br /> 1. List up to ten addresses in the space above. Select the type(s) of Tiles from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(209)4640138 S mail to the <br /> addrgss indicated ap4ve. <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$87.00 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 /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br />