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_FNUPI : NOA Environmental PHONE NO. : 209 369 4228 Dec. 03 2002 02:54PN P2 <br />UAI k NECENED_ <br />� �� ENO SOC Nl/M6ER <br />.,f�I `\i// CW-JVAQUIN COUNTYPUBLIC HEALTH SERVICES <br />'L� ENVIRONMENTAL. HEALTH DIVISION <br />O E C 0 3 2002 " 304 EAST WEBER AVENUE, THIRD FLOOR <br />STOCKTON CA 95202 0&5 <br />r�'d�l)r�l��Efv i I IE -ACTH (209) 468.3420 <br />I <br />FF�s^: iT�SFRVICPrUBLIC RECORDS RELEASE APPLICATION <br />V <br />1/✓ <br />V</ <br />APPLICANT A1561 F-AC <br />yC,-�O BUSINESS/AGENCY Alb+ iEN%Jl P_0N MEN _._ <br />TA <br />ADDRESS t/! Z^� �; U S V- i v LAfJE LO -D I <br />PHONE l �t� "rT�'— T�'� FACSIMILE (7,M) 31afq <br />` 42-2-? <br />TENTATIVE* APPOINTMENT DATE 17-- TIME •• GWN <br />(Please give 7 to 10 business days from date of application submittal <br />CHECK BOX TO EXPEDITE REQUEST - $89.00 FEE -REQUEST PROCESSED IN 3 RDS 11 cloys :5114 <br />SIGNATURE OF APPLICANT DATE <br />FILE ADDRESS ctyZ� THIS SIDE EHD STAFF USE ONLY <br />�- � PROGRAM ELEMENTS SEARCH <br />I i2q Al• GviLA Avt• i -45.51T Al. 6 -vi IA . <br />9 UNDERGROUND TANK (USI) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />Q SOLID WASTE FACILITY <br />127.4 i c�}orr 11 1 �' <br />❑ FOOD FACILITY <br />a SOLID WASTE VEHICLE <br />I& UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ DOG KENNEL <br />❑ DAIRY <br />HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ PKG TREATMENT PLANT <br />, <br />d MOTEL/HOT>:L <br />❑ PUMPER TRUCK/YARD/CHEM TOILETS <br />DO r <br />❑ POOL/SPA <br />❑ LAND USE APPLICATION SITES <br />OZCIS Awe ,o t_ <br />❑ PUBLIC WATER SYSTEM <br />I�i OTHER (PLEASE SPECIFY ABOVE) <br />2( &. C4. <br />133 �. '1"v✓►1rc✓ Fel. <br />ENVIRONMENTAL HEALTH DIVISION FILES 1 L L ZV <br />9 UNDERGROUND TANK (USI) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />Q SOLID WASTE FACILITY <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />a SOLID WASTE VEHICLE <br />I& UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ DOG KENNEL <br />❑ DAIRY <br />HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ PKG TREATMENT PLANT <br />�O TIERED PERMITTED FACILITY <br />d MOTEL/HOT>:L <br />❑ PUMPER TRUCK/YARD/CHEM TOILETS <br />(J TATTOO/BODY PEIRCING <br />❑ POOL/SPA <br />❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY <br />❑ PUBLIC WATER SYSTEM <br />I�i 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 selected. Fax to (209) 464-0138 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. <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 $89.00 deposit prior to review. <br />S. *TENTATIVE appointment dates must be confirmed with EHD staff. <br />G. Applications received after 3:00 pm will be processed the next business day. <br />CONFIRMED APPOINTMENT DATE. TIME <br />DATE CONFIRMED PHONE FAX <br />REVIEWED YES NO <br />REVIEW DATE <br />INITIALS <br />