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SAN JO- -Ulie€ GQi NrfPU8LIC HF-ALT i :SE: 1C"''C� <br /> 6l1R(?Ik MENTAL HEALTH D1VIS OLi <br /> 304 EAST WEBER AVENUE,THIRD I=LO p E C 1 4 00 <br /> STOCKTON CA 95202 I <br /> (209)468-3420 IRONIAENT [HEALTH <br /> VRO LIG RECORDS RELEASE APPLICA.�I & r ^ S <br /> APPLICANT BUSINES$[AGEN, aduaM <br /> CA 957-w <br /> ADDRESS �(J J 1.�y 1 s o a c // 5` <br /> PHONE <br /> TENTATIVE*APPOIAITUENT DATE i IME <br /> (plane give 7 to 10 business clays from data of ap1111"1ian auba"'tai) k <br /> � 1 <br /> CHECK Box TO EXPI;gITE REQl1£.Sr- p E-RE VEST PROCESSED IN 3 aUS1#1E5S DAYS <br /> DATE <br /> SIGNATURE OF APPLICANT Z• t l �� <br /> FILE ADDRESS <br /> r <br /> 2 S-O!tke <br /> f � � <br /> r <br /> t <br /> 4"�a'wjc <br /> =q\aia <br /> -- ?�!fRdq Q v►,vc,4� test + +- <br /> NVIRCNIt F-NTAt HEAL H gl1fi51C3N FILES 1 <br /> CI �oLtO WASTE FACILITY <br /> !�( UNpEReROUNII"TANK(UST)CLEANUP SITE(LOP) C HOUWNG ABATEMENT 0 SOLI©WASTE <br /> FACILIT <br /> OTHER CLEANUP S[TE(NON-LOPI 0 FOG FACILITY <br /> l!Q UNDERGPOUND TANK(MONITORINGlRE MrOVAL) ❑ DOG KENNEL 0 FAIRY <br /> M HAZARDOUS WASTE GENERATOR C1 MO-CEENOTE CH Q PU TRFAYUCKt'PLANT <br /> 0 'Tl!<RED PERMITTED FACILIYY Q 6M1gTF11HOTPL C] pUry1PERTRUCIWARDlCHENt TOILETS <br /> CI 'nERED PERMI PEi17FACI 0 POoUSPA IO LAND USI-APPLICA10ONSIT'ES <br /> 0 1a>= T001 S0DY E MCINGF&MUT0 PUULIC WATER SYs'IE ME [7 OTHER(PLEA51=SPECIFY ABOVE) <br /> I List up to fan addresses In the spaCe above. Select the types} Of firs from the list abgvc by checking <br /> the appropriate bax(es). At least one file type.MUST be selected. F'ax to 209 464-013 or mail to the <br /> a dress indicated above. <br /> 2. END will notify tt�a applicant If any lTl`iD files exist. An appointment for rev9ekv veill be confirmed ; <br /> approximately will <br /> notify <br /> five applicant <br /> business days but no-later than ten (10)days$iter receipt of application. The files <br /> will be held for a maximum of five business days for reviaw. Appointments should be scheduledactordir�gty. <br /> 3. A'file that is actively being wracked an by EHD staff may not l]e 1MMediateiy available for review. Anew <br /> appllcaifon may be submitted wh'an tate file iu avallabfe, <br /> 4. Any file riot rctUrnCd art the same condition as released will be reorganized by EHO staff at the expense <br /> of the applicant. Future file reviews by the same applicant may require a$78.00 deposit prior to MVIeW, <br /> 5_ �l ENlTATIVE appointMent dates must be Confirmed with EHD staff. <br /> 6. ,kpplicatlons received after 3:00 pm witl be processed the next business clay. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMCa PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EH W 14 OvgaOa <br />