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11H IL hLLLIYLU <br /> EHD LOU NUMk3tK + <br /> SAN JOAQUIN COUNTY <br /> n EE�_" ��iIV E�DJ ENVI AMENTAL HEALTH D PARTMEI k#1 <br /> i <br /> 304 EAST WEBER AVENUE,THIRD FLOOR- <br /> APR 1 203 STOCKTON CA 95202 <br /> (209) 468-3420 <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> I <br /> APPLICANT C BUSINESSIAGENCY <br /> ADDRESS <br /> PHONE �t t 6 -7 r - c> `1` FACSIMILE <br /> NT IVE*APPOINTMENT DATE TIME <br /> (Please give 7 to 10 business days from date of application submittal) t44-03 <br /> CCC Fz <br /> CHECK 80X TO EXPEDITE REQUEST-$89.00 FEE--REQUEST PROCESSED IN 3 BUSINESS'.DAYS <br /> a <br /> SIGNATURE OF APPLICANT DATE <br /> FILE ADDRESS ! THIS SIDE EHD STAFF USE ONLY <br /> 1 PROGRAM ELEMENTS EARCH <br /> hk <br /> (sem <br /> << r H <br /> ENVIRONMENTAL HEALTH DIVISIONiFILES', <br /> 'eV <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 13HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> �5l OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY i ❑ SOLID V(ASTE VEHICLE ) <br /> I1 UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ':� )M DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH U PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL I ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOOIBODY PEIRCING ❑ POOUSPA ❑ LAND USE APPLICATION SITES <br /> 13 MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) i <br /> 'I F <br /> 1. List up to ten addresses in the space above. Select the type(s)l'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 <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) day's afterreceipt of application. The files <br /> will be held for a maximum of five business days for review. A' poinfinents should be scheduled <br /> accordingly. s <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. !. <br /> 4. Any file not returned in the same condition as released will be"reor anized by EHD staff at the expense <br /> of he applicant. Future file reviews by the same applicant may requite a $89.00 deposit prior to review. <br /> 5. *TENTATIVE appointment nates 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 /> } <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHD 4M2-006 <br /> 312612003 - <br /> 0 <br /> i <br />