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DATE DECEIVED r cn�wv wn��i <br /> ri „ Sli`� SAN JOAQUIN COUNTY <br /> `� ' U ERONMENTAL HEALTH DEPARMENT <br /> F E B 1 9304 E Weber Ave Yd Floor Stockton, CA 95205 <br /> 468-3420 Fax. (209)464=0138 Web: www.co.san_joaquin.ca.US/ehd ' <br /> r NViHul' MENI HEALTH <br /> ''"T/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT:—� nk7 i4 „t L) BUSINESS/AGENCY: <br /> ADDRESS*. 1r� <br /> PHONE:. C -3�3 _ FACSIMILE: 2S 7-Z6,76 <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE—'REQUEST PROCESSED IN 3 BUSINESS DAYS I <br /> SIGNATURE OF APPLICANT DATE Z 11 b <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> 1. Street S r4.0 a -S 7Z>C777 �i Unit f <br /> i. street ^J1 <br /> 3. $creek .. •^4���� <br /> Unit 2 <br /> 4. Sbtet ❑ dt � <br /> S. suet CRY it 3 <br /> 6. Street _ <br /> r. Suet a Unit 4 <br /> e. suet <br /> City <br /> s. street City ❑ Unit 5 <br /> 10. Sheet a <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> r OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY D SOLID WASTE VEHICLE <br /> ❑ UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILrrY ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDfCHEM TOILETS <br /> ❑ TATTOOIBODY PIERCING ❑ PooLfSPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> 1. List up to ten addresses in the space above. Select the type(s)of files from the list aboye by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(2091464-0138 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 APPOINTMENr-DATE. ` TIME <br /> DATE CONFIRMI±p : PHONE.:. FAX'' .INITIALS' <br /> 'REVIEWED YES NO REVIEW DATE--::-.a <br /> ' �ttD 48-02.006 i <br /> Rl8f;00� I <br />