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06/15/2004 09:44 2099316743 WATERL00 SHELL PAGE 01 <br /> DATE RECEIVED EHD LOG NUMBER <br /> F� J - ;,i � SAN 3OAQ•J:T COUNTY <br /> � �� ICU ENVIRONMENTAL HEAL'T'H DEPARTMENT <br /> 304 E Weber Ave 3`d Floor Stockton, CA 95205 <br /> JUN 1 5 2W) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESWAGENCY: <br /> ADDRESS: zz (� <br /> PHONE: J 6 7 V FACSIMILE: <br /> TENTATIVE`APPOINTMENT DATE: Tin* <br /> (Please allow 10 business days from date of application Submittal) <br /> El CHECK BOX TO EXPEDITE REQU T-$9 EE—RE ROCS D IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE d <br /> Department Use my <br /> FILE ADDRESS UNIT <br /> 1 street ❑ Unit 1 <br /> 2. stwt CRY <br /> J � <br /> s. s,—, Unit 2 <br /> a. street �' <br /> 5 sve� <br /> 8. 3ireet <br /> 7. s,", a 11Unit 4 <br /> e svtx <br /> e sinot ON ❑ Unit 5 <br /> 10. s+—, Cit <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) O HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOUD WASTE VEHICLE <br /> ��� UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH O PKG TREATMENT PLANT <br /> 11 TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCKIYARD/CHEM TOILETS <br /> O TATTOO/BODY PIERCING O POOL/SPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> 1. List up to tett 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 -0136 or m 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 avallable 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. f=uture file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> S. '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 r <br /> EHP aea24)06 r lIJ -.L. (�G7 <br /> UU2003 7 _7f <br /> I`C.,� — g - <br />