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SAN JOAQUIN COUNT <br /> �J — ENVIRONMENTAL HEALTH DErARTMENT <br /> 304 E Weber Ave 3n1 Floor Stockton, CA 95205 <br /> kMAR 0 5 M 468-3420 Fax: (209)464-0138 Web: www.co.san-joaquin.ca.us/ehd 1 -7 <br /> NVIRUIVNitIV 1"HEALTH PUBLIC RECORD <br /> R S RELEASE APPLICATION <br /> APPLICANT' �C'�-}V��j ✓,_—V�" jy�G�CUZ� BUSINESS/AGENCY: <br /> ADDRESSS�:"*„2 ' yrr_' c— mD v <br /> ss <br /> PHONE: 1ZLk5I �—� FACSIMILE: <br /> TENTATIVE'APPOINTMENT DATE: <br /> Time: <br /> (Please allow 10 business days from date of application submittao <br /> 13 CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE—REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT <br /> DATE <br /> Department Use Only <br /> FILE ADDRESS <br /> t. so-cet �M�il UNIT <br /> 2. s Unit 1 <br /> 3. sunt4. \ <br /> O <br /> s"� ❑ Unit 2 � <br /> S. s� <br /> S. s 1 a Unit 30'0 <br /> a + Unt4 <br /> 9. S4e <br /> 10, so- nit 5 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY OTHER CLEANUP SITE(NON{OP) ❑ FOOD FACILITY <br /> \ UNDERGROUND TANK(MONITORINGIREM OVAL) ❑ DOG KENNEL ❑ SOLID WASTE VEHICLE <br /> :ES HAZARDOUS WASTE GENERATOR 13 CHICKEN <br /> ❑ TIERED PERMITTED FACILITY ❑ CHICKEN RANCH 13PKG TREATMENT.PLANT. <br /> ❑ TATTOO/BODY PIERCING MOTEUHOTEL 11 PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ MEDICAL WASTE FACILITY ❑13OOTHER A 11 LAND USE APPLICATION SITES <br /> THER(PLEASE SPECIFY) <br /> 1• Ust 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 <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. <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 /> S. '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 APPOINTMENTDATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> Eno"422 s <br /> artrzoot <br />