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I - <br /> I c t VED <br /> SAN JO kQUIN COUNTY EHD LOG NUMBER <br /> ENV)(RONMENTAL HEALTH DEPARTMENT <br /> APR 2 9 20044 304 E Weber Ave 3'd floor Stockton,CA 95205 <br /> ri�1VIi�,UNMENI HE Ppg {468-3420 Fax: (209)464-0138 Web: www.co.san-joaquin.ca.us/ehd <br /> PFRMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESSIAGENCY:-SE ,()(L!�R('-NIA - ua, <br /> ADDRESS: IZP,3y IS - Gd;t_ kUL, w W lA el-Kest <br /> PHONE: (Lf ss S 151I FACSIMILE: (L47 t _3"l 7,- I E OC) <br /> TENTATIVE'APPOINTMENT DATE: Time; <br /> (Please allow 10 buslneoa days from date of application submlttatI <br /> CHECK BOX TO EXPED(TE RE EST-$93. E—RE UEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLIC DATE �a oy <br /> Deo <br /> FILE ADDRESS UNIT \'�� ���G� <br /> il.t` ,. stroe In <br /> —� - (G>� <br /> (,awl o cxv d Unit 1 V <br /> r� � <br /> ofl'ZC c O 9 ❑ Unit 2 <br /> 5, 5tmm it 3 <br /> 5 8"et /yt <br /> 7 8tnot COYV <br /> a st m CRY <br /> s� <br /> c4r, ❑ Unit 5 <br /> ctr _j <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑ UNDERGROUND TANK(UST)CLEANUP SITE(LOP) In HOUSING ABATEMENT In SOLID WASTE FACILrry <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> ❑ UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ;M HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYAR=HEM TOILETS <br /> ❑ TATTOO/BODY PIERCING ❑ POOL/SPA ❑ 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 above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(209)46"138 or mail to the <br /> address indicated above. <br /> 2. EHD will notify the applicant if any EHD flies 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 app lican may regdire a$93.00 deposH prior to review. <br /> 5. `TENTATIVE appointment dates must be confirmed with EHO staff. <br /> 6. Applications recelved after 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE 'nME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHD 49424M <br /> gn=04 <br /> 000 TOO HODaS OS9TZLCSZV %Vd 9V:CT MU tO/6Z/tG <br />