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EHD LOG NUMBER <br /> DATE RECEIVED SAN JOAQUIN COUNTY <br /> Int 'W/ LL <br /> El!CIRONMENTAL HEALTH DEPART-e✓IENT 15 <br /> 304 E Weber Ave 3rd Floor Stockton, CA 95205 00- <br /> $E P 1 2 Z0 <br /> O 9)468-3420 Fax: (209)464-0138 Web: www.co.san-joaquin.ca.us/chd I <br /> 1VVItiJNiv1EN1 HEALTH <br /> °ERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION.Ir / <br /> APPLICANT: 1J((LLt t I j /�n 0� BUSINESSIAGENCY: C c l C 0/ <br /> ADDRESS: /P, Q F u Kl W�' S r �r�T c' T �1 n <br /> PHONE: 00 Z� 1 L/ 1 FACSIMILE: 2-0 9 ?- 39- <br /> 3 0 ,530 <br /> L-0A.3 <br /> TENTATIVE'APPOINTMENT DATE: �/i COT �!y Time: <br /> E2 <br /> // (Please allow 70 business days from date of application submittal) <br /> E2 CHECK BOX TO EXPEDITE.REQUESI',-193.00 FEE—REQQ/UEST PR,OC SSED.IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT ( DATE <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> x t, sVee J"qq75 C/ /t to C f V c Unit 1 <br /> _S io a a Iy <br /> I. s.. 25l/ C 1 r _ Gty <br /> - _ ,. .. _.. _. ❑ <br /> 3. sveet 2 o C �3 <br /> ❑ Unit 2 (,`V ,l <br /> 5. street c <br /> y � J <br /> 5. Street Q �� 3 <br /> 7� 6. street Z n�� a <br /> 7. street 2' l.r cal, ✓n. Unit4 <br /> a. street �i .S Ci <br /> s. str«t G .. Unit 5 <br /> ky <br /> 10. street Ci <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES r + 4 " <br /> Cd"�l1NDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT <br /> UATEENT ❑ SOLID WASTE FACILITY- <br /> V� c THER CLEANUP SITE(NON•LOP) C3 FOOD FACILITY - ---0 SOLID WASTE VEHICLE - <br /> Wr UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEVHOTEL ❑ PUMPER TRUCKIYARD/CHEM TOILETS <br /> ❑ TATTOOIBODY PIERCING ❑ POOUSPA - ❑ LAND USE APPLICATION SITES <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 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$93.00 deposit prior to review. <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications received after 3:00 pm will be processed the next business day. j <br /> Im <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHD WW2003'`°` G( 7?vt : Mk, l✓) F t r n q ih s u s �o r 71�. C l b Pr <br />