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I <br /> Nn <br /> SAN Jl .JUIN GOUN7YPUBLIG HEATH Si / ICCs <br /> ENVIRONMENTAL HEALTH DIVISION 304 EAST WESERAVENUE, THIRD FLOOR <br /> 5700p STOCKTON CA 95202 <br /> �� I MENT HEALTH (los) 468-3420 <br /> 1f&TH (PUBLIC RECORDS RELEASE APPLICATION <br /> ` \\ ( 4PPLICANT — BUSINESWAGENCY aduaJ p�G & V��� <br /> G ft <br /> ADDRLSS O ] / V • LL) S Q C CA / J 5;;Z0S�� i <br /> ` <br /> CI PHONE -IDD FACSIMILE <br /> ti = A3 * APPOINTMENT DATE . TIME <br /> �d t; ` = (Please give 7 to 10 busino$A a from date of appiiGaean Submittal) <br /> rim 8.00 FEE EQUEST PROCESSED. IN 3 BUSINESS DAYS _.,` �V / �GL INI z=� <br /> SIGNATURAF `A' PkICANT o DATE <br /> FILE ADDRESS CA, ) <br /> AA k49 2� <br /> mac, O <br /> i <br /> i <br /> ENVI ONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK (UST) CLEANUP SITE (LOP) 11HOUSING ABATEMENT ❑ SOLID! WASTE FACILITY <br /> I. <br /> OTHER CLEANUP SITE (NON-LOP) ❑ FOOD FACILITY'k?;- C:3 SOLID WASTE VEHICLE <br /> UNDERGROUND TANK (MONITORINGlREMOVAL) ❑ MG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH E7 PKG TREATMENT PLANY <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRIICKIYARDICHEM TOILETS <br /> ❑ YATrOOBODY PEIRCING M 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 selocted. Fax to (209) 464-0136 or mail to the <br /> address indlcated 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 laterthan 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 /> I 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 $78.00 deposit prior to review. <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications recefved after 3: 00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> Ik PHONE FAX INITIALS <br /> DATE CONFIRMED <br /> i <br /> REVIEWED YES NO REVIEW DATE <br />�I fN 00 14 D110VN <br />