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L. Juu /V1J I1LL1.\I'BLUEIC Ljkf Ul <br /> — --—— — EHD LOG NUMBER <br /> � flll hID SANJOAQULN COUNTY - <br /> l� <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> MAR 0 5 2004 304 E Weber Ave 3d Floor Stockton,CA 95205 <br /> (209)468-3420 Fax: (209) 464-0138 Web: www. . -}oaquin.ca uslehd <br /> cosan <br /> ENVIRON':"iEI'�T HEALTH <br /> PERNIJ SERVICES PUBLIC RECORDS RELEASE�ApPP�APPLICATION <br /> BUSINESS/AGENCY: <br /> AF PucANT: G <br /> ADDRESS: Ti �C) _ <br /> PHONE: l_��� l ✓� A r� ' FACSIMILE: <br /> Timer <br /> TENTATIVE*APPOINTMENT DATE: \�yAp1p,p submlttel) <br /> D` <br /> (Please allow 10 business ays <br /> Profl <br /> �da a 0t <br /> In CHECK BOX TO EXPEDITE REQUEST =93.00 FEE-R EST PROCESSED IN 3 BUSINESS DAYS <br /> DATE <br /> SIGNATURE OF APPLICANT <br /> Department Use OnIY <br /> UNIT <br /> FILE ADDRESS <br /> ql q C�i a u <br /> cly <br /> S"e Unit <br /> Unit 3 <br /> a s 2j Z Unit 4 <br /> e S"e 0 Unit 5 L <br /> 9 StreN <br /> �1 0 <br /> 10 S&ew <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES Ct , --�j3 <br /> / <br /> ❑ HOUSING ABATEMENT SOLID WASTE FACILITY 1 -s-+- '7 7 IV- <br /> UNDERGROUND TANK(UST)CLEANUP SITE{LOP) ❑ FOOD FACILITY jIt SOU D WASTE YEHI E <br /> UNDERGROUND <br /> CLEANUP SITE(NON-LOP) ❑ DOG KENNEL ❑ DAIRY ��Crl�%'� _ J J h (1 <br /> 'VUNDERGROUND TANK(MONITORINGIREMOVAL) ❑ CHICKEN RANCH •�-.PKG TRF NT PLANT EM TOILETS r, � <br /> HAZARDOUS WASTE GENERATOR ❑ MOTELIHOTEL ❑ PUMPERTRUCKIYARDICH PAvl1.t <br /> 0 TIERED PERMITTED FACILITY ❑ POOL/SPA �-AND USE APPLICATION SrTES <br /> ❑ TATTOO/BODY PIERCING ❑ OTHER(PLEASE SPECIFY) <br /> ❑ MEDICAL WASTE FACILITY checking <br /> List up to ten addresses In the space above. Select the type(s)of files from the list above by <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(209 41 64-0138 or mail to the <br /> address indicated above. EHD fifes exist. An appointment for review will be confirmed <br /> 2. EHD will notify the applicant if any <br /> y s after receipt of application. The files <br /> approximate) five business days but no later than ten(10) day ointments should be scheduled <br /> will be held for a maximum of five business days for review. App <br /> accordingly. <br /> 3. A file that is actively being worked hen the ftiEe is staff <br /> ta lab a not be immediately available for review. nev <br /> application may be submitted <br /> released will be reorganiz <br /> 4 Any file not retuat the expens( <br /> rned in the same condition same applicant may require a$93.00 deposit prior to ev ev <br /> of the applicant. Future file reviews by <br /> 5. *TENTATIVE appointment dates must be confirmed with END staff. <br /> 6. Applications received after 3:00 pm will be processed the next business day. <br /> TIME <br /> CONFIRMED APPOINTMENT DATE INITIALS —!— <br /> PHONE FAX <br /> DATE CONFIRMED <br /> REVIEWED <br /> YES NO REVIEW DATE <br /> 4"2nos <br /> &v7%3 <br />