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Jun, 2, 2005 2:51PM WNCED G10 No. 0833 P. 1 <br /> DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> II En mONMENTAL 14EALTH DEPARTMENT ® <br /> 304 E Weber Ave 3rd Floor Stockton, CA 95205 "3 ^ <br /> SUN 02 Zob)468-3420 Fax: (209)464-0138 Web:www.co.san­joaquin.ca.us/ehd <br /> ENMRDWENT HEALTH P LTC RECORDS RELEASE APPLICATION <br /> /� ov/}� <br /> APPLICANT: USINESS/AGENCY: a,fua[�+1CCd �C77U/Iyiome II a I <br /> ADDRESS:/]f r�U7 3n ry� ,�T <br /> PHONE: - y& / ` 1CJ611Y FACSIMILE: 42?07 7/W / VIII <br /> TENTATIVE"APPOINTMENT DATE: aE uku Tema: <br /> ` aTute hosi from II n aubmittai) <br /> CHECK BOX TO EXPEDITE REFERE U Y PRO E O 1 3 SINE55 DAYS <br /> SIGNATURE OF APPLICANT DATE S <br /> Department Use Only <br /> j6+49 FILE ADDRESS UNIT !!! <br /> D^I� e�ei K 9� gayL• 9 Z — Cu El Unit 1 <br /> 2. 6Veet <br /> s sv.a ❑ Unit 2 <br /> U/ e , <br /> a C eolooeunit 3 <br /> e. sheer <br /> 30 r — <br /> s. she: 000) !UA a cn �9 R ❑ Unit s <br /> ,0. SheaW320 1 G C 1 <br /> TTT,,,rrr ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> �y UNDERGROUND TANK(UST)CLEANUP SITE(LOP) D HOUSING ABATEMENT d SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY 17 SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL O DAIRY <br /> HAZARDOUS WASTE GENERATOR D CHICKEN RANCH D PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑ MOTELHOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ TATTOOOODY PIERCING D POOLISPA ET LAND USE APPLICATION SITES <br /> 0 MEDICAL WASTE FACILITY D 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(2091464-0 38 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 tiles <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 TIME <br /> DATE CONFIRMED PHONE. FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> sxn ere-oa-0ue <br /> 91BI20 W <br />