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a(ceG?ejr LJ ] t (C '/ �� LHU LUG NUMUIH <br />V� .7d/\ N JOAQUIN COUNTYPUBLIC HEALTH SERVICES <br />8� ENVIRONMENTAL HEALTH DIVISION rX, <br />304 EAST WEBER AVENUE, THIRD FLOOR 0 -0l� <br />KTON STO <br />MAR 2 8 2000 C -3 0 <br />(209) 468-3420 <br />CA 9 9 <br />cNViHUN,VI-NTA. - 1=APUt-ELIC RECORDS RELEASE APPLICATION <br />t : a nI <br />APPLICANT Quid 1� BUSINESS/AGENCY I.T'Q(I 0, 6�SU <br />ADDRESS (�krJ % UULL-\Ly' w1 <br />Z-.370) <br />PHONE 2.01 36 ! -3GD) FACSIMILE <br />TENTATIVE' APPOINTMENT DATE Ap rr 13 — 7 i Ow U TIME '06) 0 WI <br />(Please give 7 to 10 business days frorn date of application submittal) <br />CHECK BOX TO EXPEDITE REQUEST -- $78.00 FEE -REQUEST PROCESSED IN 3 BUSINESS DAYS <br />. <br />SIGNATURE OF APPLICANT (1 dj C/`A L , DATE ac('C 0 <br />HIS SIDE EHD STAFF USE ONLY <br />PROGRAM ELEMENTS SEARCH <br />/'esr <br />O <br />0 <br />0 <br />ENVIRONMENTAL HEALTH DIVISION FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />HOUSING ABATEMENT <br />.4'L!3C) <br />M"" OLID WASTE FACILITY <br />OTHER CLEANUP SITE (NON -LOP) <br />CI <br />FACILITY <br />❑ SOLID WASTE VEHICLE <br />UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ <br />DOG KENNEL <br />❑ DAIRY <br />HAZARDOUS WASTE GENERATOR, <br />❑ <br />CHICKEN RANCH <br />❑ PKG TREATMENT PLANT <br />TIERED PERMITTED FACILITY <br />❑ <br />MOTELIHOTEL <br />❑ PUMPER TRUCK/YARD/CHEM TOILETS <br />❑ TATTOO/BODY PEIRCING <br />❑ <br />POOL/SPA <br />❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY <br />❑ <br />PUBLIC WATER SYSTEM <br />❑ 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 (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 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 $78.00 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 />REVIEWED YES NO REVIEW DATE <br />