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-:0,APA Jt�—t"i'LUHN WUNTYPUBLiC HEALTH ICES <br /> 4VIRC)NMENTAL HEALTH QIVIS1 <br /> - -3�4 EAST WIEBEk AVENUE,THIRD FLOOR k7; I <br /> �`�r,,"'' ? STOCKTON CA 95202 . V�(209)468-342D `=Y <br /> PUBLIC PECORDS RELEASE APPLICATION <br /> 'App <br /> LIC"T[ BUSINESSIAGENCY_ 7C, ,] S o4►ItvS <br /> ADDRESS f �0 L CJS _ r I s ir� W C1�+►t r <br /> PHONE_: q. �' . 7 { r FACSIMILE _ _- r " <br /> ''TENTATIVE*APPOINTbMNT D3 m 10 : t7 a , M . <br /> l <br /> (Please give T-to-i o busing=aays from date Of application Submi(eai) <br /> I <br /> 13 Oiscf BOX TO EXPEDITE REQUEST-S87,04 FEE-BEQUEST PROJEBSIED IN 3 SUSINESS MAYS <br /> -SIGNATUkE OF APPLICANT DATE Alt- <br /> /7 <br /> � <br /> 4 <br /> ! FILE An-RES- THA SIDE F-HD S'T'AFF USE ONLY <br /> PROGM14 ELEMENTS SEARCU. <br /> a c- F< <br /> Al <br /> i <br /> 4 <br /> i ENY,1R0NmENTAL ti ALTH Dri sm I'll-ES <br /> I <br /> UNDERG NO TANK(UST)CLEMUP SITE(LOP) ❑ HOUSING ABATEMENT © SOMO WASTE FACILffY <br /> A GTKER qLE.ANUP SITE(NION-LOP) ❑ FOOD FACILITY 0 SOL16 WASTEVEHICLE <br /> UNDERGROUND TANK(MONITMN IAEU16VAL) El DDG KENNEL 0 DAIRY <br /> HAZARD '.1S WAS`rE GENERATOR 0 CMICKIEN PANCH O PKG 1,TREATMEr4T PLAMT <br /> TIERED vWtTTEI?FACILITY Q NoTW- HOTEL Q PUMPERTRUCKNARDICHEMTOILF-7S <br /> D TATT;O;;ODY PEACIHG 0 POOL/WA d LAND USE APPI,ICATI6U SITES <br /> ❑ MEDICAL'WASTE RACrLt7 Y 0 pUSLIC WATER SYSTEM 0 OTHER(P'LE"E,SPECIFY AUOVE) <br /> I <br /> 1. mist up to tern addresses in tl�e space above. ;Select the type($) of files from the list above by checldng <br /> fyle appropriate box(es). Af least one file type MUST be selected. Fox to, 209)469-4i3a or rnafl ty,thR <br /> a drLjdjGated-above, <br /> 2. F p will,notify the applicant if any EHD files exist. An appointment for review will be c6nfirmed <br /> �3pprox4nately five ousiness nays but no later than tett ('i0)days after receipt:of application. The files <br /> Vyil1 be held for a maximum of five business days for review. Appointments should be srheduled <br /> accord i n�1y. <br /> 3. file that is actively being worked on by JEW Staff may not be immediately available for review. A new I <br /> pplicatian may be submitted wren the file is avaiiable. <br /> 4. Any fibs not returned in the some condition as released will be marganized by ESD staff at the expenso <br /> Of the applicant. Future file reviews by the same applicant may require a$87.4D deposit prior to review. <br /> 5. *M4TATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications receivedafter3:00 prrlw2l be pro,Cessed the nextbusiness day. <br /> 1 . <br /> CONFIRMAPPOINTMENT DATE <br /> TIME <br /> DATE CONFIRMED PRONS FAX INITIALS <br /> ! <br /> I <br /> REVIEWED YES NO REVIEW DATE <br /> F.ti 44 pa/07r46 <br /> TOTAL P.02 <br />