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SAN X IUIN COUNTYPUBLIC HEALTH SrVICES <br /> j� ENVIRONMENTAL HEALTH DMSIO— <br /> 304 EAST WEBER AVENUE,THIRD FLOOR APR 2- 01000 <br /> STOCK'rON CA 95202 <br /> (2a�} a6�-saga Clwlf;(1Ivft�,E(�!l-AL HEALTH <br /> PUBLIC RECORDS RELEASE APPLICATION PElzl,4ITisERv!cEs <br /> APPLICANTnc. <br /> USINES3/AGENCY L(llL�Q17CQl� [ISO t/+u� � �� L <br /> ADDRESS_`? S • CA/,, S�tJS` <br /> PHONE �D (/ FACSIMILE /I <br /> TENTATIVE'APPOINTMENT DATE TIME <br /> (Please give 7 to 10 business days from date of applicatfo i smittal) <br /> (Earlier Sheer hoe,S (�rtorl � Pt'rarllt ,. l\ <br /> HECK BOX TO EXPEDITE REQUE $73.00 FEE-REQUES ROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> E ADDRESS - -. <br /> Y► I 7`�d <br /> It <br /> o27-Sr3 <br /> corn n cs a7 <br /> Ave- <br /> L a <br /> j f1 <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> 1!9- UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> qI OTHER CLEANUP SITE(NON-LOP) D FOOD FACILITY C SOLID WASTE VEHICLE <br /> )I. UNDERGROUND TANK(MONITORINGtRENOVAL) D DOG KENNEL D DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH D PKG TREATMENT PLANT <br /> G TIERED PERMITTED FACILITY ❑ NOTELIHOTEL G PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOC780DY PEIRCING L7 POOUSPA M LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY D PUBLIC WATER SYSTEM ElOTHER(PLEASE SPECIFY ABOVE) <br /> 1. List up to ten addresses In the space above, Select the types) 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 then ten (10) days after receipt of applicatlon. 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 wilt 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 received after 370D 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 /> EH Oa 11- OLVD5,00 � <br /> S� r�� �A(Z 1 a-j-� <br />