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[DATE RECEIVED <br />SAN JOAQUIN COUNTEHD LOG NUMBER <br />Y <br />EN:'4ONMENTAL HEALTH DEPARTMVT <br />OCT r304 E Weber Ave ra <br />3 Floor Stockton, CA 95205 <br />20209) 468-3420 Fax: (209) 464-0.138 Web: www.co.san-joaquiii.ca.us-/L*hd' <br />PUBLIC RECORDS RELEASE APPLICA <br />APPLICANT: BUSINESSIAGENCY: admj 6lewS(%r <br />ADDRESS: O � Q e <br />i <br />PHONE.-% f, -� �Q� FACSIMILE: D <br />TENTATIVE" APPOINTMENT DATE: CV_r _ Time: <br />(Please allow 10 business days from data of application submittal) <br />a <br />CHECK BOX TO EXPEDITE REQ97Z <br />- REQUEST OCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE a <br />Department Use Only <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNIT <br />�L ❑ Unit 1 <br />�� ❑ knit 2 <br />3 r <br />Unit 4 <br />Unit 5 <br />PIDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />❑ SOLID WASTE FACILnY <br />FILE ADDRESS <br />❑ FOOD FACILITY <br />' 1, <br />SSreel <br />11 <br />C BL <br />❑ DAIRY <br />f1 <br />G L Cv <br />2. <br />street <br />W _ t <br />❑ MOTELIHOTEL <br />ci <br />3. <br />street 1 <br />• k. 1. <br />ILACi <br />city <br />`i 4. <br />Street Tv�l <br />�0All <br />• <br />city <br />?.5. <br />Street <br />Ii irv0 0 <br />L <br />G 0 <br />B. <br />s1real <br />Y 10 <br />.-7. <br />Street <br />city <br />8- <br />Street <br />city <br />' 9. <br />SUeet <br />city <br />10- <br />Street <br />Ci <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNIT <br />�L ❑ Unit 1 <br />�� ❑ knit 2 <br />3 r <br />Unit 4 <br />Unit 5 <br />PIDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />❑ SOLID WASTE FACILnY <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />❑ SOLID WASTEIVEHICLE <br />UNDERGROUND TANK (MONITORINGIREMOVAL) <br />❑ DOG KENNEL <br />❑ DAIRY <br />HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />EI PKG TREATMENT PLANT <br />131�'flERED PERMITTED FACILITY <br />❑ MOTELIHOTEL <br />❑ PUMPER TRUCKIYARDICHEM TOILETS <br />❑ TATTOO/BODY PIERCING <br />❑ POOLISPA <br />❑ LAND USE APPLICATION SITES <br />INI'MEDICAL WASTE FACILITY <br />❑ 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. <br />CONFIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED _ PHONE FAX INITIALS <br />REVIEWED YES NO REVIEW DATE <br />EHD 48-02-008 - <br />87812003 <br />