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r r'. 7T0 oo U 5 • OC 1011 CUWSl.11, uJ�+- <br /> LHO LUG NUMa A <br /> SAN . QUIN COUNTYPUBLIC HEALTH 'aWICES <br /> NVIRONMENTALHEALTH DiVIS( <br /> ' ST WEBER AVENUE,THIRD FLOOR <br /> �z p <br /> s ? * <' € ,. STOCKTON CA 95202 <br /> (209)468.3420 <br /> FEB 20UMIC RECORDS RELEASE APPLICATION <br /> '-r��(�NC�4�P�4-r; { L. HL LTH BUSINESSIAGENCY t n v��:trr t lc>bculYi.ru��� <br /> APPLICANj` ,.t. r Jam. . Ji�� _� <br /> N ItA <br /> ADORESS <br /> PHONE 9Ih t Z — 'l fill 7 FACSIMILE 416 F7 -71�hL7 <br /> TENTATIVE'APPOINTMENT DATE TIME <br /> Ir-ee77�� (Please Blwe�to t0 business days from date of apPllca[ion submi1ta11 <br /> alc11ECK BOX TO EXPEDITE REQUEST-$16.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> D ` DATE <br /> SIGNATURE OF APPLICANT <br /> 7\ FILE ADDRESS <br /> i 1 <br /> y <br /> r t <br /> l <br /> o 9 cal jAW4 1 ,y I DLtI (r�sews T 7 <br /> L CAZ c"' L' <br /> ENVIRONMENTAL HEALTH DIVISION FIL <br /> "U U ❑ SOLID WASTE FACILITY <br /> W UNDERGROUND TANK(UST}CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT 13 SOLID WASTE VEHICLE <br /> C j9YHEft CLEANUP STYE(NON-LOP) ❑ FOOD FACILITY ❑ DAIRY <br /> ElprUNDERGROUND TANK'MONITORINCJREMOVAL) ❑ DOG KENNEL ❑ PK{a TREATMENT PLANT <br /> [3 WASTE GENERATOR ❑ CHICKEN RANCH <br /> ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARTIICHEN TOILETS <br /> ❑ TIERED PERMiTTEU FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ TATTOOIBODY PEIRC ING ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> ❑ MEDICAL WASTE FACILITY <br /> 1, List up to ten addresses in the space above. Select the type(s)of Faxfiles from the list above m checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax o 2091 46d-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. at the <br /> 4. Any file not returned in the same condition as releasedlll be t ma reorganized <br /> $78y00 dap sEHD f prior to review. <br /> se <br /> of the applicant. Future file reviews by the Same app Y 4 <br /> uifO ed <br /> 5 STENTATIVE cations received after 3:00 pm caointment dates must l be pro essedlthe next business day. <br /> D staff. <br /> 6. APP <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED <br /> PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> E W 14 U1N <br />