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03/26/2003 11:37 2094671118 AGE STOCKTON PAGE x_11/01 <br /> DATE RECEIVE J AHD LOG NUMBER <br /> ✓ "N JC,,cQUIN COUNTYPUBLIC HEALTH S�dICES <br /> / ENVIRONMENTAL HEALTH DIVISION <br /> MAR 2. 6 2003 304 EAST WEBER AVENUE,THIRD FLOOR / <br /> ST (209)46 CA 95202 <br /> In.11'!i',�itl� I NF I' (209)466-3420 <br /> c 1 ;,inti ELIC RECORDS RELEASE APPLICATION <br /> APPLICANT a BUSINESS/AGENCY ^ h2 694&yl�j2 <br /> ADDRESS �/} /�)�/Q C7� (21Q 95; �sI' _ <br /> PHONE C;V7 7W� - AX ILI FACSIMILE - _2 'I <br /> /r� <br /> TENTATIVE'APPOINTMENT DATE <br /> -y� TIME ,1L!'✓ti�_- 3 �3 C / <br /> (Please give 7 to 1 business days from date of application submittal) <br /> HECK BOX TO EXPEDITE REQ ST-$11111,00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS Uri' <br /> SIGNATURE OF APPLICANT DATE <br /> FILE ADDRESS T T- <br /> — - W <br /> ty AF <br /> F ' <br /> : <br /> ENVIRONMENTAL HEALTH DIVISION FILES A <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) d HOUSING ABATEMENT d SO41D WASTE F kClUTY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> IN UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> O CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> • TIERED PERMITTED FACILITY 0 MOTEUHOTEL 0 PUMPER TRUCI ARDICHEEM TOILETS <br /> ❑ TATTOOIBODY PEIRCING O POOLISPA rJ LAND uSEeppl.ICATION SITES <br /> ❑ MEDICAL WASTE FACILrrY 0 PUBLIC WATER SYSTEM ❑ OTHER(PLEAS SPECIFY ABOVE) <br /> 1. List up to ten addresses in the space above. Select the type(s) of files from the lis above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax t(? 2( 09) 4•_E'4 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 a) plication. The files <br /> will be held for a maximum of five business days for review. Appointmrnts shout be scheduled <br /> accordingly. <br /> 3. A file that is actively being worked on by EHD staff may not be immediately a I or vi A new <br /> application may be submitted when the file is available. 10% AW AV <br /> 4. Any Tile not returned in the same condition as released will be reorganized b " :t <br /> of the applicant. Future file reviews by the same applicant may require a$78.00 deposit prior torevs.w. <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 INITIAL <br /> REVIEWED YES NO REVIEW DATE _ <br /> EN 00 14 01roL00 — ---- <br />