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UUI Lit LUUJ 1 f Ul <br />DATE RECEIVED <br />" t 1 _7= <br />FF PD, <br />RDECCZ <br />AUG 1 6 2004 <br />1 r• <br />404uloo <br />LNVIKUNMENIAL HEALTH <br />PAGE 01 <br />3AN JOAQUIN COUNTY <br />ENVII~.,,,,IMENTAL HEALTH DEPARTMENT . <br />304 EAST WESER AVENUE, THIRD FLOOR <br />STOCKTON CA 95202`a 6 G ti \\a L • i _ , _/ <br />(209) 468.3420 (18 J <br />PUBLIC RECORDS RELEASE APPLICATION <br />QJ L�3 <br />PERM <br />APPI.ICANT�%�n� W��S-e, BUSiNESSIAGENCY \L)� ;� ' ^ � <br />to <br />S <br />ADDRESS \\J� � S� � <br />PHONE Z v" r � <br />FACSIMILE Z u ' 2- 7 <br />TENTATIVE* APPOINTMENT DATE �� lc + s P TIME <br />(Please give 7 to 10 business days from date of application submittal) Lo 0 <br />q-3.00 <br />CHECK BOX TO EXPEDITE REQUEST - S FEE - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />DATE $ 2 t <br />SIGNATURE OF APPLICANT <br />1 <br />C3 SOLID WASTE FACILITY <br />9 UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING AS ❑ SOLID WASTE VEHICLE <br />10 OTHER CLEANUP SITE (NON4-OP) ❑ FOOD FACILITY ❑ DAIRY <br />N UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ DOG KENNET, ❑ PKG TREATMENT PLANT <br />0 HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PUMPER TRUCKIYARD/CHEM TOILETS <br />O TIERED PERMITTED FACILITY ❑ MOTELIHOTEL O LAND PSE APPI..I ATION SITES / <br />❑ TATTOO/BODY PEIRCING a POOLJSPA <br />00 <br />❑ MEDICAL WASTE FACILITY 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 checkin <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. y ointment for review will be confirmed <br />Z. EHD will notify theapplicant if an EHD files exist, An appointment lication. The files <br />approximately five business days but no later than ten (10) days ointments should er receipt Of li scheduled <br />will be held for a maximum of five business days for review. App <br />accordingly. not be immediately available for review. A new <br />3. A file that is actively being worked on by EHD staff may <br />application may be submitted when the file is available. expense <br />4. Any file not returned In the same condition as released anit ma ll be reorganized ire a $89.00 deposit prior to review.of the applicant. Future file reviews by the same app Y <br />3, *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 <br />PHONE FAX INITIALS <br />REVIEWED YES NO REVIEW DATE <br />