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hep, L. 2UUb IU: IIAM No- 2539 P. 1/2 <br /> DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.or /eh <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: kGNYIelyh 5L9jY1 L BUSINESS/AGENCY: <br /> ADDRESS: i✓I W— Skr><P� City/State/zIp 1101 G qy <br /> PHONE(1): J�-/(WO XLOJ PHONE(2): FACSIMILE: .Z 3 <br /> TENTATIVE`APPOINTMENT DATE: 2z t ZOOS Time: q,," <br /> (Please allow 10 business days from dates application submittal-"Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$�1 SS ff/E(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT / i�/�i���lrr� L O <br /> Electronic Informat <br /> 4D USE ONLY <br /> Street tl <br /> -- � Unit 1 <br /> 2. 2 C -- - <br /> El Unit 2 <br /> 3. <br /> 4. 665 -- _ - 4UnIt3 <br /> Unit 4 <br /> 6, <br /> 8. s ❑ Unit 5 <br /> 9• 0 <br /> 10. -- ❑ Unit 6 <br /> Specific Date Range of <br /> tAZARDOUS <br /> NDERGROUND TANK(US 1_ :ACILITYNEHICLE <br /> THER CLEANUP SITE(N( ��,L'�j,�•//`y/5 <br /> NDERGROUND TANK(MG--- ---- - <br /> WASTE GENF rREATMENTPLANT <br /> 0 TIERED PERMITTED FACILI ---- ---/YARD/CHEM TOILETS <br /> O TATTOO/BODY PIERCING JGATION SITES <br /> 0 MEDICAL WASTE FACILITY <br /> WELL AND SEF------ — ——--- -- --_- — - :LUDING HOLIDAYS. <br /> i. List up to ten addre: <br /> priate <br /> box(es). At least ons dicate above.oAddress <br /> ranges will not be a( plications received after <br /> 3:00 pm will be prod <br /> 2. The EHD will notify t ned approximately ten(10) <br /> days after receipt of -_ __. --- ---evlew. Appointments <br /> should be schaduler--- <br /> 3. A flie that Is actively _. _-. . A new application may be <br /> submitted when the,-------- <br /> 4. Any file not returned In the same condition as released will be reorganized by EHD staff at the expense of the applicant_ <br /> Future file reviews by the same applicant may require a$105 deposit prior to review. <br /> EHD USE ONLY <br /> EHD 48-06 8/04108 PUBLIC RECORDS RELEASE APP FORM <br />