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Un 1 [_ nCl.Gi v Gu SAN JOAQUIN COUNTY V ENV )N11ENTAL HEALTH DEPART: .kT APR 0 6 304 E Weber Ave 3`d Floor Stockton, CA 95205 ��) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd ENVIRu iii l� -iv l HEALTH PFP^"'J/SERVICES PUBLIC RECORDS RELEASE APPLICATION � I BUSINESS/AGENCY: ATc. APPLICANT: J,�V,.. Kv�. J �r Ssocl., et ADDRESS: 1117 Lo,-,c,,4v< Sv.?e-B , %looiesA, C,4 PHONE: -2,0C' - 5,7 9- 22,21 FACSIMILE: -2J9 ' 57`1' 2225 TENTATIVE* APPOINTMENT DATE: Time: r �+ (Please allow 10 business days from date of application sub; CHECK BOX TO EXPEDITE REQUEST- $93.00 FEE -REQUEST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OF APPLICANT I DATE `t-' 6 -04"' Department Use Only UNIT EIED Unit 1 Unit 2 q1 8 9 ne6�� Unit 4 ❑ Unit 5 ENVIRONMENTAL HEALTH DEPARTMENT FILES UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT SOLID WASTE. FACILITY' a OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT ' ❑ TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS ❑ TATTOOIBODY PIERCING ❑ POOL/SPA ❑ LAND USE APPLICATION SITES ❑ MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECIFY) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address indicated above. 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately five business days but no later than ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a $93.00 deposit prior to review. 5. *TENTATIVE appointment dates must be confirmed with EHD staff. 6. Applications received after 3:00 pm will be processed the next business day. CONFIRMED APPOINTMENT DATE TIME? DATE CONFIRMED PHONE FAX INITIALS REVIEWED YES NO REVIEW DATE EHD 48-02-006 8!82003 FILE ADDRESS 1. Street p ulp Y ` V // i✓ o4 W + Ci Sf- IC o H 2. Street et O 6O S� 4l O✓ aty S'1 •o :.K . 3. Street 6119 S. 4ir o1 - W aty sfo,�'- Street 6122- S. r ovW cityS f Y o u.4..1 M45 5 1 Street O OZO S —� . v! W- city 5f-&, Nw 6. rA IL T- Street 2000 5 f roti „Ua v city 7. Street 503 S . i or 1 �✓ .�f citySt-o("" Es Street 3611 S. 4��a �✓. r�v�?�L. a�C'�l�E/nom 9. $Seel-/ \�l.oT S • 471;a V• V ci �o 10. Street city Department Use Only UNIT EIED Unit 1 Unit 2 q1 8 9 ne6�� Unit 4 ❑ Unit 5 ENVIRONMENTAL HEALTH DEPARTMENT FILES UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT SOLID WASTE. FACILITY' a OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT ' ❑ TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS ❑ TATTOOIBODY PIERCING ❑ POOL/SPA ❑ LAND USE APPLICATION SITES ❑ MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECIFY) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address indicated above. 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately five business days but no later than ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a $93.00 deposit prior to review. 5. *TENTATIVE appointment dates must be confirmed with EHD staff. 6. Applications received after 3:00 pm will be processed the next business day. CONFIRMED APPOINTMENT DATE TIME? DATE CONFIRMED PHONE FAX INITIALS REVIEWED YES NO REVIEW DATE EHD 48-02-006 8!82003