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{ DAIEWXLIVti7 <br /> SAN ►I' 'rAEJ10�OG NUMBER <br /> ,- QUIN COUNTYPUBLIC HEALTH,_'' 'RVICE'S <br /> ENVIRONMENTAL HEALTH DIVIS <br /> 304 EAST WEBER AVENUE,THIRD FLOOR <br /> STOCKTON CA 95202 <br /> I (209)468-3420 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT BUSINESS/AGENCY <br /> ADDRESS 157. GAG _ <br /> 3 7— <br /> PHONE 20 -- 7157 — 17 FACSIMILE 09 -36 -02— 8 <br /> TENTATIVE"APPOINTMENT DATE <br /> TIME <br /> (Please give 7 to 10 business daysI(fcm <br /> date of ap ligation submittal) <br /> �IJOZ'� <br /> CHECK BOX 70 EXPEDITE REQUEST-X89.0IFIE �EQUE T PESSLt 1 3 9US1S4 r;. .,, ;. <br /> SIGNATURE OF APPLICANT n. ' - t-' ',• ;r +- <br /> DAfIr�n <br />{ FILE ADDRESS ti THIS SIDE EHD STAFF USE ONLY <br /> PROGRAM ELEMENTS SEARCH <br /> as 1 c <br /> `7 3 s on v <br /> 4 ih <br /> C h 2 ri <br /> ENVIRONMENTAL HEALTH DIVISION FILES - <br /> gr—UNDERGROUND TANK(UST)CLEANUP SITE(LOP) eHOUSING ABATEMENT ❑ SOLID WASTE FACILITY L�Y <br /> BOTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY 0 SOLID WASTE VEHICLE <br /> 0`UNDERGROUND TANK(MONITORINGIREMOVAL) 01"DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR MICHICKEN RANCH Cl PKG TREATMENT PLANT f <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELJHOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS JV <br /> 83*-TATTOOI13ODY PEIRCING M-POOUSPA BLAND USE APPLICATION SITES COv•Vc <br /> 0 MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 9. 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) 454-0138 or mail to the <br /> address indicated above. <br /> 2. EHD will notify the applicant if any EMD 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 $89.00 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 /> k <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> • n <br /> L. <br /> REVIEWED YES NO REVIEW DATE <br />