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(1 <br /> HID LOG NUMBER � <br /> tEIVED SAN COC.OtJNTY • <br /> RE <br /> til I "ijt�i <br /> U� E LSU�I L� L� �'NNgR0 NMFNTAj,WALTH DEPARTMENT <br /> 304 E Weber Ave 3d Floor Stockton, CA 95205 <br /> APR l 7 2006(209) 468-3420 Fax: (209) 464-0138 Web: www•oO.San joaquin-ca.us/ehd <br /> ENVIRON ILN i I;ErQ PUBLIC R, CORDS RELEASE APPLICATION <br /> p_ 'F .. � fel � b✓��fi� ��c <br /> APPLICANT:Q ` 1Yl(La�x)l�.a,., BUSINESS/AGENCY: <br /> ADDRESS: `�� : ,L11�L11Y <br /> PHONE <br /> TENTATIVE- <br /> ���` FAOSIMILE:_ 9tq <br /> TENTATIVE`APPOINTMENT DATE: <br /> (Plea3e allow 10 bvsinens days from date of application submittal) <br /> © CHECK 13OX TO EXPEDITE REQUEST-$93.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> rt 1 DATE -. <br /> SIGNATURE OF APPLICANT pepanment Use Oniv <br /> UNIT <br /> FILE ADDRESS <br /> l' . cm ❑ Unit 1 <br /> i. 54ee1 (N ��.E..-. CIN S_ <br /> 2. Weal pA�.7-...� L+— Cllr tT/0CVy_ L�� C] Unf 2 <br /> Ir <br /> 4 Sim' <br /> Unit 3 <br /> 5. 51mU <br /> Gil <br /> T. em.-t <br /> GI <br /> B. St.et ❑ Unit 5 <br /> a, Strte1 <br /> CI <br /> ia. MET <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> -/ ❑ SOLID WASTE FACILITY <br /> f� UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 FOOD FACILITY ABATEMENT CI SOLID WASTE VEHICLE <br /> d OTHER CLEANUP SITE(NON-LOP) ❑ DOG KENNEL ❑ DAIRY <br /> Gds//UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ CHICKEN RANCH O PKG TREATMENT PLANT <br /> H AZAROOUS WASTE GENERATOR ❑ MOTELlH01'EL ❑ PUMPER TRUCKryARDICHFM TOILETS <br /> Ck TIERED PERMITTED FACILITY D POOLISPA El LANE)USE APPLICATION SITES <br /> ❑ TAT'TOOIBODY PIERCING D 011IER(PLEASE SPECIFY) <br /> ❑ MEDICAL WASTE FACILITY <br /> List up to ten addresses in the space above. Select the types) of files from the list'a38 o m checking <br /> the appropriate bo%(eS). At least one file type MUST be selected. Fax to 2092464-0136 or mail to the <br /> address indicated above. <br /> z, EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> t of�r The files <br /> approximately five business days but no later than <br /> an ten (10) days ointments should receipt of pbe scheduled <br /> fter <br /> will be held for a maximum of five business days for review. App <br /> accordingly. <br /> ctively being worked on by EHD staff may not be immediately available for review. Anew <br /> 3, A file that is a <br /> application may be submitted when the file is available. <br /> 4• Any file not returned in the Same condition as releas e same I cant mayl be reorganized <br /> $93 00Hdeposfit prior to review. <br /> of the applicant. ointment dates musFuture file revieV, t brs by e confirmed with EHD taff. <br /> g, "TENTATIVE app <br /> 6. Applications received after 3:00 pm will be processed the next business, ay. <br /> T)MF — — <br /> CONFIRMED APPOINTMFNT DATE INITIALS _ <br /> DATE CONFIRMED PHONE FAX <br /> REVIEWED <br /> YES NO REVIEW DATE <br /> Ena 4E42-39E <br /> NW003 <br />