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DA JAN, 29. 2H4 1 .27PN1 CON50R EARTH TECH NO. 2576 ;F• 1OGlVUMBEF <br /> SAN JOAQ)UIN COUNT <br /> -rte ENVIRON1IENTAL HEALTH DEPARTMINT <br /> t'�� �� r) 3041✓Weber Ave 3T'Floor Stockton, CA 95205 <br /> JAN292004(209)468-3420 Fax (209)464-01.38 Web; www. .co.san-joaquirI_ca.us/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> PF Uq�p t-� (`�() C ZBIIS1NFSslAGENCY: �aaO& � �A 1�r� <br /> ADDRESS:_ ! O fir_f�•k1 ANit r oF, <br /> PHONE: J -,2 3 9— LEO 7 FACSIMILE:lszxt <br /> TENTATIVE"APPowTmENTDA�� 1 r Time. A n <br /> (Please allow 10 business days from date of application submittal) r` I <br /> 13 CHECK BOX TO EXPEDITE REQUEST-393.00 FEE-REQUEST PROCESSED 1N 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT � - DATE <br /> Dep of Use Only <br /> FILE ADDRESS UNIT <br /> i. SN, LSD ❑ Unit 1 <br /> z Sime, City <br /> 3. sveet �� Unit 2 " <br /> 51 <br /> �t <br /> 5. s"e-y aty nit 3 <br /> sem, �Unit,4 <br /> a. 51rml oty <br /> 9. Street d ❑ Unit 5 j <br /> 1 � <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) CI HOUSING ABAT9MENT SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY SOLID WASTE VEHICLE ( l <br /> C UNpE,GROUND TANK(MONITORING1RrmovAL) t7 DOG KENNEL DAIRY L I� <br /> 1�HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT F � <br /> j TIERED PERMRTED FACILnY 0 MOTELIHOTEL a PUMPER TRUCKIYARD/CHF-M TOILETS w <br /> ❑ TATTOO/8013Y PIERCING 17 PoOUsPA J2-r LAND USE APPLICATION SITES <br /> Q MEDICAL WASTE FACILI'T'Y O OTHER(PLEASE SPECIFY) l�(J <br /> 1. List up to ten addresses in the space above, Select the type(s)of files from the list aboye by checking <br /> the appropriate box(es)- At least one fila type MUST be selected. Fax to (2091464-0138 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 worsted 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 release'a 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 3:04 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 /> Exo 4111-07-90 <br /> aa1s9a3 . <br />