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SAN JOAQUIN COUNTY <br /> �! -, -,' .�L.l\ iRONMENTAL HEALTH DEPART 1v1ENT <br /> 304 E Weber Ave 3'd Floor Stockton, CA 95205 <br /> MAR 0 5 ( 468-3420 Fax: (209)464-0138 Web: www.co.sanjoaquin.ca.us/ehd <br /> 1 -7 1P <br /> 4�XNV1HU1&1L1d 1 HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> allTrnrnt nn <br /> r �-r <br /> 1-1 1-r�'0"'.�rn i <br /> APPLICANT I \C WA- 7 L—V-- 1h\Ve U� <br /> 1 � BUSINESSlAGENCY: <br /> ADDRESS:��� Yp <br /> PHONE:\k \ S�_ Z <br /> FACSIMILE: <br /> TENTATIVE'APPOINTMENT DATE: <br /> Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FE — %�. � <br /> E REQUEST PROCESSED IN 3 BUSINESS DAYS i A. �nnQ <br /> SIGNATURE OF APPLICANT <br /> DATE <br /> Department Use Only <br /> FILE ADDRESS <br /> 1. Street r�Ck 7'V UNIT <br /> 2. Street <br /> 3. Street ❑ Unit 1 <br /> 4. Street <br /> s. Street it Unit 24\0\ <br /> 6. Street <br /> 7. Street Unit 3 <br /> S. Street <br /> Unit <br /> 9. Street <br /> 10. Street <br /> oty ❑ Unit 5 <br /> \ ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> lk`3 UNDERGROUND TANK(UST)CLEANUP SITE(Lop) ❑ HOUSING ABATEMENT\ <br /> OTHER CLEANUP SITE(NON-LOP) ❑ F000 FACILITY ❑ SOLID WASTE FACILITY UNDERGROUND TANK(MONITORINGIREMOVAL) 11 DOG KENNEL ❑ SOLID WASTE VEHICLE <br /> �j HAZARDOUS WASTE GENERATOR ❑ DAIRY <br /> 13TIEREDPERMITTED FACILITY CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TATTOO/BODY PIERCING ❑ MOTELMOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ MEDICAL WASTE FACILITY ❑ POOUSPA ❑ LAND USE APPLICATION SITES <br /> ❑ OTHER(PLEASE SPECIFY) <br /> 1. List up to ten addresses in the space above. Select the types)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 <br /> TIME <br /> DATE CONFIRMED PHONE . <br /> FAX INITIALS <br /> REVIEWED _ YES NO REVIEW DATE <br /> EHD 48-02-006 <br /> &M'2003 <br />