Laserfiche WebLink
05/16/2005 BON 10:22 FAX 20412 7986 Berum-Crabtree-Brown . R001/001 <br /> REMWID SAN dOAQUIN COUNTY EHD LOG NUMBER <br /> 1•;NVIRpNMENTAL HEALTH DEPARTMENT <br /> MAY 1 6 9(105 304 E Weber Ave 3rd Floor Stockton,CA 95205 17077 <br /> (209)468-3420 Fax: (209)464-0138 Web:www.co.san-joaquin,rit.us/clid <br /> ENPEOU114ENT HEALTH PERI IC RECORDS RELEASE APPLICATION <br /> pE�al�rcGRtnr•FS <br /> (1���� <br /> APPLICANT: ��.ixlP� �. 61,-I'hm; 11(t- BUSINESSIAGENCY, IICF ti.r1 0/1 <br /> ADDRESS: L- I rl tr { L11ju ' rl e- P <br /> PHONE: .71JC) '�^^�t'{2 - 7-700 7 J .�•G; <br /> TENTATIVE'APPOINTMENT DATE: Time: <br /> (Please allow 19 business days from date of application submittal) <br /> © CHECK BOX TO EXPEDITE REQUEST-S9 Aa-FEe; ES CE �^D/IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT ^ �/1 DATE <br /> J <br /> -� DePanment Use Only <br /> FILE ADDRESS UNIT <br /> 91met %ss - I ay 111 > Mf; ZN/o <br /> 2. 34ea1 <br /> E] Unit 1 <br /> Cil <br /> 3. SkpM <br /> [] Unit 2 <br /> �. 6una CA <br /> o4 Unit 3 <br /> c. saum cy <br /> o4 <br /> unit <br /> svom ClyUnit 4 <br /> a. Mot CA <br /> a. 6hea CA <br /> ❑ Unit 5 <br /> o. smwi cn <br /> y.l(705 ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) O HOUSING ABATEMENT 0 SOLID WASTE FACILITY <br /> THER CLEANUP SITE(NON-LOP) 0 FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) 0 DOG KENNEL Cl DAIRY <br /> HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH 0 PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY 0 MOTELIHOTEL 0 PUMPER TRUCKIYARDICHEM TOILETS <br /> D TATTOOIBODY PIERCING 0 POOLISPA 0 LAND USE APPLICATION SITES <br /> 0 MEDICAL WASTE FACILITY 0 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 mall to the <br /> address Indicated above. <br /> 2. EHD will notify the applicant if any END 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 /> S. `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 /> k&1iIEWEI] YES NO REVIEW DATE <br /> ENO 0A-0S-0OG ` <br /> END" `J/ I b/dam : le(f vii 119,ter,�b(r.�• Oaeh Skt w�� 51 vl r0 A�PSt- n Ve aASo I-6 I I Ilam <br />