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'lW.IvFC� 0 <br />L D <br />SAN aTOAQUIN COUNTY EHD LOG NUMBER <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />JUN 2 4 2004 304 E Weber Ave 3 Floor Stockton, CA 95205 <br />ENVIRONMENT 42ADL9�4 68-3420 Fax: (209) 464-0138 Web: www.CD.san-joaquin.ca.us/ehd <br />PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br />MPL.ICANi;��Q-fro l4, ZS1LN( A_ BUawESSIAGENCY: CCGtx�rJ �iMJSuL�-pct3T��. IC.• <br />AooREss IInD (znt 1 V�ctd�tt AI <br />A�V/1 Qoo RA�`�y'+�bonalv,.rCAS� <br />gq2 <br />PHONE �lt..)]r R�% ^'II I FACSIMILE: -IID^ ASI" �iI tJZ <br />TENTATIVE" APPOINTMENT DATE: M )rR kd I U1 Tune: <br />(Phase allow 10 butlness days from dale of appllcetlon stsbmlltal) <br />CHECK BOX TO EXPEDITE REQUEST - $93,00 Ore REQUEST P TED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE _-UL9 ; . <br />DapW6rd Use OMy . <br />❑ Unit i <br />Unit 2 <br />❑ Unit 5 <br />UiV <br />ENVIRONMENTAL HEALTH DEPARTMENT 0.ESt o 64dnly � , _ ,tat UNDERGROUND TANK NST) CLEANUP SITE (LOp) ❑ HOUSING ABATEMENTSOLID WASTE <br />fW OTHER CLEANUP SITE (NON -LOP) ❑FOOD FACILfTY P SOLID WASTE VEHICLE <br />)2 UNDERGROUND TANK (MONITORIN(UREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br />R HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br />IBDTIERED PERMITTED FACILITY 0 MOTELIKOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br />❑ TATTOOIBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br />0 MEDICAL WASTE FACILITY 0 OTHER (PLEASE SPECIFY) <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 H 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 woMad 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 $93.00 deposit prior to review. <br />S. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br />S. 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 />Ealoseaxsoe .--. - <br />amu^' <br />