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16:27 CRMBRIR <br />1707"93 6649 P.01101 <br />SAN JOOW COUNTYPll6LIG HEALTH SE�CES <br />/ . ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, THIRD FLOOR <br />STOCKTON CA 95202 7 1Z <br />Pt" LIFIRLIC RECORDS9RELEASE APPLICATION <br />APPLICANT i b-Ir-(.:Qp <br />ADDRESS <br />BUSINEsvAGENCY QzLm6 iii 15i,4'Irwm1 elnA4-1 <br />PHONE_09-7) 933- 23(x$ FACSIMILE <br />CM. <br />MI <br />TENTATIVE' APPOINTMENT DATE a-\9 TIME ��a� <br />tRE) <br />v T I° �fJ`�daYs a(e of ap cation submiftaq <br />CHECK 80X TO EXPEDITE RE -Se .00 FEEOIIEST PED IN BUSINESS PAYS <br />SIGNATURE OF APPLICANT DATE <br />��• ---' I THLS SIDE EHD STAFF USE ONU <br />PROGRAM ELEMENTS SEARCH <br />e0 <br />ENVIRONMENTAL HEALTH DIVISION FILES V UU1BJt1 �0 I'f'0 <br />r 9UNDERGROUND TANK (UST) CLEANUP SITE (LOP) C3 HOUSING ABATEMENT p SOLID WASTE FACILITY u L'�LLJJ <br />0THER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE q S <br />UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL CI DAIRY ^/ <br />❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH C3 PKG TREATMENT PLANT <br />O TIERED EDFACILITY 0 MOTEUHOTEL p <br />• TATTOO/BODYIBODY PEIRCING PUMPER TRUCKrYARDlGHEM TOILETS <br />ID MEDICAL WASTE FACILITY CI POOUSPA ❑ LAND USE APPLICATION SITES <br />❑ PUBLIC WATER SYSTEM 0 OTHER (PLEASE SPECIFY ABOVE) <br />�• 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) 464-0138.2r 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 />31 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 />S- "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 />t)ATE CONFIRMEI] PHONE FAX <br />INITIALS <br />REVII=WE) YES NO REVIEW DATE <br />TOTAL P.01 <br />