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, EM)4UG NUMDEN <br /> SAN J %QUIN COUNTYPUBLIC HEALTF ERVICES <br /> " ENVI MENTAL HEALTH DIVISON <br /> 304 EAST WEBER AVENUE,THIRD FLOOR <br /> ' <br /> STOCKTON CA 95202 <br /> (209) 468-3420 <br /> / PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT �{�ri.5 '��'�b i7 z.p� BUSINESSIAGENCY <br /> ADDRESS (2Nlh/rlw��-w.4K:. �cfy - I t� j� t��w.�i (2 <br /> PHONE S/D3c/o2 FACSIMILE S/r-, <br /> TENTATIVE'APPOINTMENT DATE TIME - <br /> (Please give 7 to 10 busln day to of application submittal) <br /> 48 <br /> CHECK BOX TO EXPEDITE REQUE F IRE .LEST W ED IN 7 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE /U '3 1 -O <br /> FILE ADDRESS THIS SIDE EHD STAFF USE ONLY <br /> PROGRAM ELEMENTS SEARCH <br /> fruMlft D <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> ❑ UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> ❑ OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE _ <br /> ❑ UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ TATTOO/BODY PEIRCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ 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 ton (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. 1 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 $89.00 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 />