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N J► JUIN COUNTYPUBLIC HEALTH S VICES <br /> �NViRONMENTAI HEALTH DIVISIO�ti <br /> us304 EAST WEBER AVENUE,THIRD FLOOR eUS"d <br /> STOCKTON CA 95202 J� <br /> (209) 4653420 / <br /> PUBLII.C� RECORDS RELEASE APPLICATI <br /> APPLICANT La A#1f CJS BU3-1NL33/A0E7NCY <br /> ADDRESS 2-337 Xij a_aj. <br /> PHONE_20__'YFACSIMILE <br /> lJ / ► • <br /> TEIYlATiVE`APPOINTMFN7DgTE r es o/ TIME �•U=J �; <br /> (Pleat$give 7 to 10 busln •s days from date of applicatlon submittal) vl <br /> CHECK BOX TO EXPFOITE REQUES 78.04 FEa -REQUEST ROC SSED!N 3 Elu5tNE55 DAY5 <br /> SIGNATURE OF APPLICANT DATE -oar <br /> f <br /> FILE ADDRESS <br /> n <br /> /r tt !M . .23 1 301 a 3TF, <br /> Ir of---------------------- <br /> 1 fr <br /> rf r r is f` /. <br /> L <br /> Milne", a3o1 f Zo <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> } UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING A13ATEMEHT ❑ SOUD WASTE FACILrrY <br /> �i OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY [ISOL 0 WASTE VEHICLE <br /> IJNaCRGROUNA TANK JMQNITORING/REMOVAL) '0. 000 KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREAYTAENT PLANT <br /> M Til=RED PERMITTED FACILITY ❑ MOTELIHOTC-L ❑ PUMPER YEtUCKfYARWC:HEM TOILETS <br /> ❑ TATTOOIBODY PEIRCING ❑ POOL(SPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ PUSUG WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by chocking <br /> the appropriate box(es). At feast one file type MUST be selected_ Fax to (20[9) 464-0138 or mall to the <br /> dress indicated above. <br /> 2. EHD will notify the applicant it any EHD files exist. An appointment for review will be confirmed <br /> approximately rive 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 reviow. 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 $78.00 deposit prior to review. <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications recalved 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 /> Fk as t otiio un <br /> .o <br />