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EHD LOG NUMBER <br /> DATE RECEIVED R SAN JOAQUIN COUNTY <br /> I.J) E. <br /> ll� C)j ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br /> -OCT �2Q%3t68-3420 Fax: (209) 464-0138 Web: w.ww.co.san-j'o'aquin'.ca.us/chd rt <br /> �-NV II�O�q� ;[N i ,iEHLt rl.PUBLIC RECORDS RELEASE APPLICATION <br /> . <br /> APPLICANT: 44&�2_BUSINESSIAGENCY, <br /> ADDRESS:�� PCS�TK�I R'^�T xf e"fZA9 FiS�L n <br /> o - w <br /> PHONE: FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) 4 <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE—REQUEST PROCESSSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT - L DATE - <br /> Department Use Only <br /> FILE ADDRESS' UNIT <br /> 1. street f City < D ❑ Unit 1 <br /> CI <br /> 2. Street c <br /> tv <br /> 3. Slree[ ✓ city f ❑ Unit 2 <br /> 4. Street ON <br /> Yv <br /> 5. street G' . lir fi ;�+ Cis L Unit 3 <br /> 6. Street G I <br /> 7. Street ON Unit 4 <br /> 8. Street Git <br /> 9. Street Cit Unit 5 <br /> 10. Street Ci <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY ! <br /> OTHER CLEANUP SITE;(NON LOP) 0 FOOD FACILITY ID SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) 13 DOC,KENNEL 0 DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY 0 MOTELIHOTEL 0 PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOOIBODY PIERCING 0 POOLISPA 0 LAND USE APPLICATION SITES I <br /> MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPE=CIFY) <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 i <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. i <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 /> EHO 48-02.006 <br /> WM003 - <br />