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SeP . 4. 2003 12 :43PM -a')NDOR EARTH TECHNOLOGIES No .4879 P. iii <br /> DAI=Kit-cwty - I _ <br /> r - F.. SAN JOAQiITN COUNTy -r�.' rr,u LUG NUN cJ <br /> ENVIRO <br /> NMNTAL HEALTH D"AR3:MENT <br /> 304 E Weber Ave P Floor Stockton, CA 95205 <br /> S E P n 4 2RGP9)468•-3420 Fax: (209)464-0138 Web:www.co.saa joaquip,ca_us/ehd <br /> NVikuNMENT HEALTii pUBLIC RECORDS RELEASE APPLICATION <br /> _ . <br /> APPLICANT: t3US1NEs3/AGENCY: F,?O ' !� aLll <br /> ADDREss: S� c t S�` `~TOG KTo <br /> PHON u- O ! FACSIMILE: -- (> S�3 <br /> TENTATNE;APPOINTMENTDAM 1 Jc"" ` ,yo d� Time. ^` <br /> (Please allow 10 business days from date of applicatlan submittal) <br /> CHECK BOX TO EXPEDITE REQUES?�3.00 FEE--REQUEST ROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT �� DATE <br /> Department Uee Only <br /> FILE ADDRESS UNIT <br /> ,. sheetO W• �rcti <br /> City [J Unit t <br /> 2 sheet Yr1 "t. c <br /> a sheet l d '—st . �arUnit 2 <br /> I <br /> 3trrat -1 ...�•. I"'ta.f'rLson/S-Lim CClLA.�c <br /> S <br /> s. s t ( Unit 3 <br /> city <br /> 7. c f 55 nit 4 <br /> e. Sh,mt 405 L vt t -ply <br /> S. Str.et D I/lOY"a c, Lam}? nit 5 <br /> ,o. s <br /> 7a IW3552# <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT 1r SOUD WASTE FACILITY.. <br /> OTHER CLEANUP SITE(NON-LOP) 17 FOOD FACILITY 00 SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) CI DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR CI CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> 95 TIERED PERMITTED FACILITY a MOTEL/HOTEL 8 PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOO/BODY PIERCING 0 POOL/SPA W LAND USE APPLICATION SITES <br /> MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPFr-1cv1 <br /> 9. List up to ten addresses in the spa I st above py checklnl <br /> the appropriate box(es). At least o. r / I-099$ or rs�ait to the <br /> address Ir,�dic�ated above. (� <br /> 2. EHD will notify the applicant If any I be confirmed <br /> approximately five business days h plication. The files <br /> will be held for a maximum of five>r be acltedLttsd <br /> accordingly. <br /> 3. A file that is actively being worked 4 tie for review. A ne' <br /> application may be submitted when <br /> 4. Any file not retumed in the same co staff at the ®xpens <br /> of the applicant. Future file reviews posit prior to-revim <br /> 5. *TENTATIVE appointment dates mu: <br /> 6. Applications received after 3:00 pm, <br /> CONFIRMED APPOINTMENT DATE. - <br /> DATE CONFIRMED <br /> REVIEWED >. YES NO REVIEW DATE. <br /> EM 4642.000 <br />