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w u � <br /> SAN j�QUIN COUNTYPUBLIC HEALTHr,.cRVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,THIRD FLOOR MAR Z 7 Z001 <br /> STOCKTON CA 95202 <br /> (209) 468-3420 <br /> _ PUBLIC RECORDS RELEASE APPLICATION 1-;_;, ,;;; ,:::I_;;` ;,•E <br /> APPLICANT 3 C ( l BUSINESS/AGENCY <br /> ADDRESS <br /> PHONE I `7 (�.' FACSIMILE ( Y �'� C�U D_IT <br /> TENTATIVE*APPOINTMENT DATE TIME <br /> (Please dive 7 to 10 business days froin date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUESTT-�-$887.00/FETE—REQUEST P�R,O�CEESSSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT !,O ✓�'� � �l�`�` I DATE 3 <br /> FILE ADDRESS THIS SIDE EHD STAFF USE ONLY <br /> PROGRAM ELEMENTS SEARCH <br /> 1 <br /> f ENVIRONMENTAL HEALTH DIVISION FILES <br /> /UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> ❑ OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> ❑ UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARD/CHEMTOILETS <br /> ❑ TATTOO/BODY PEIRCING ❑ POOUSPA - ' ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ 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 $87.00 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. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br />