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11 ti t :- ��-- _�_-,�I_�_1� �NIY 4'1�t�lfV L+iJiliV l 7 i'l3fjL_I� e71C�'aL.t i'1 'tib+;.,�,.t <br /> °%m►cNVIRONMENTAL HEALTH DIVISr.A <br /> SA304 EAST WEBER AVENUE,THIRD FLOOR ►'las <br /> 01 STOCKTON CA 95204 <br /> 2 <br /> (209)468-3420 �lQ <br /> Ef•i��iF;J N i�Pi E ': r!EALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT Y1t? BUMNESSlAGENCY ad..VA,n LIQ& eA t�?[, m. <br /> ADDRESS `7DC !V UJI t SD C' `� c. DS— <br /> PHONE a� Y FACSIMILE <br /> TENTATIVE*APPOINTMENT DATIE WCC- I//V' 900 - TtMjE Ao•ij40 <br /> (Please give 7 to 10 business days from date of application submittal) <br /> CHECK SOX TO EXPEDITE REQU T-$78.00 FEE-RECQUE T R ESSED IN 3 BUSINESS DAYS <br /> J <br /> SIGNATURE OF APPLICANT DATE <br /> FILE ADDRESS <br /> a� <br /> L <br /> 3sa� /V1 <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-.OP) O FOOD FACILITY O SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONrTORINGIREMOVAL.) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY 0 MOTELIHOTEL C7 PUMPER TRUCKIYARDICHEIvi TOILETS <br /> O TATTOOIBODY PEIRCING 0 POOLISPA 0 LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1. List 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)464-0438 or mail to the <br /> address indicated above. <br /> 2. EMD 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 /> wilt 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 EHR 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$78.00 deposit prior to review. <br /> 5. "TENTATIVE appointment dates must be confirmed with EHp staff. <br /> U. Applications received after 3:00 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 /> rN 00 14 01,*51W <br /> V <br />