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io 001 <br /> 09/03/2004 10:15 FAX <br /> EHD LOG NUMBER <br /> DATE RECVrFO r-� SAN JOAQUIN COUNTY <br /> E 1 .11 I'✓� <br /> ENviRONMENTAL HEALTH DEPARTMENT <br /> 2004 304 E Weber Ave 3d Floor Stockton,CA 95205 I <br /> SEP 3 (209)468-3420 Fax:(209)464-0138 Web: www.co.san Joaquin ca-us/ehd <br /> ENVIRGp)f�ENT 9 qc;z <br /> HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> h /✓� 'j f✓r4 au✓j <br /> APPLICANT: ,,I/V27-1l, /UX BUSINESS/AGEN/CY: <br /> ADDRESS:/ `1-1 y C,-d r)Y/r✓� 1 L/-^ 4 u� ! <br /> �✓7 ]� <br /> PHONE: 1?/0 — Yy� — (?- 5 L b FACSIMIILLE: �6 — Z'- /-L/ O Z LS <br /> �LyL� J f <br /> " TENTATIVE'APPOINTMENT DATE: I� � nmt: ` <br /> (Please allow 10 business days from date of application submittal) <br /> ,CHECK BOX TO EXPEDITE REQUEST•$93. FEE-RR,AUEST PROCESSED IN 3 BUSINESS DAYS • <br /> SIGNATURE OF APPLICANT �,� DATE G/J <br /> DCP LNI Use Only <br /> _ <br /> FILE ADDRESS UNIT <br /> Z/V/ r n s� oa '� p Unit 1 <br /> r <br /> .° <br /> e sex: 0100 Unit 3 <br /> c. sec <br /> a srcro <br /> e m cry (] Unit 5 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUNO TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT 0 SOLID WASTE FACILITY <br /> 7HER CLEANUP SITE(NON-LOP) O FOOD FACILITY O SOLID WASTE VEHICLE <br /> X�JNDERGROUND TANK(MONITOPiNGIREMOVAL) 171 DOG KENNEL ❑ DAIRY <br /> RDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑ MOTELIHOTEL O PUMPER TRUCK/YARO(CHEM TOILETS <br /> ❑ TATTOO/BODY PIERCING ❑ POOLSPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY q 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 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$93.00 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 ..*1 TIME .e. _.. <br /> DATECONFIRMED PHONE:, FAX INITIALS - <br /> REVIEWED :I:::.. YES... 'NO . REVIEW DATE.... <br /> r>+o uazmc <br /> erarsaoa <br />