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U L"Rl I -V s? z L l l l U V VL A 1 A' <br /> ENI -,0 NMENTAL HEALTH DEPARTP NT <br /> 302'E Weber Ave 3`d Floor Stockton, CA 9555 <br /> JUN 1 1 20009) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd <br /> tfJVOUNIMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT:)��A/-.2- D mQ 1 f G4���BUSINESSIAGEKCY: <br /> ADDRESS: W , r,[, e �� 70 4 6 `'1 a D <br /> PHONE: D G v FACSIMILE; <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> 1. Street O W. City <br /> 2 Street M ❑ Unit 1 <br /> s. sty c: Unit 2 <br /> 4. Street <br /> 5. Stree! <br /> Unit 3 <br /> 6- Sveei G <br /> 7. Street u ❑ Unit 4 <br /> a- Street C <br /> 9. Street Cay <br /> 10. SUeei El Unitf <br /> } <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> e v> <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(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL _PUMPER TRUCKIYARDICHEM TOI T <br /> ❑ TATTOOIBODY PIERCING ❑ POOLISPA LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) C <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 /> t_Ho 48o2-006 <br /> alt1f240 S <br />