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/ SAN QUIN COUNTYPUBLIC HEALTH ' ViCES <br /> N06VIRONMENTAL. HEALTH DIVISl4 <br /> 304 EAST WE15ER AVENUE,THIRD FLOOR � ) �� <br /> STOCKTON CA 95202 <br /> (209)468-3424 <br /> tiLIC RECORDS RELEASE APPLICATION <br /> APPLICANT BUSINESSIAGENCY akadgCed <br /> saos-- <br /> PHONE 0 - (1 FACSIAi1fLE G( / � II <br /> TENTATIVE*APPOINTMENT DATE au"P,-TIME q;op Av-, <br /> (Pleme g1w 7 to to hushw�ys tr i date 9(appiication Submittal) <br /> yitECK SOX TO EXPEDI M R.EQUF-ST-S7 .00 - PROCESSED W 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT R€� DATE -7101 O D O <br /> dn <br /> FILE ADDRESS <br /> SYS ' • <br /> % <br /> �- co r6Aen _ <br /> ENVIRONMENTAL HEALTH DIVIS10k FILES <br /> �Q UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT M SOLID WASTE FACILITY <br /> I�!44 OTHER CLEANUP SITE(NON-LOP) ❑ FOOC FACILITY ❑ SOU10 WASTE VEHICLP <br /> UNDERGROUND TANK(WNITORINGMEMBMOVAL) 0 DOG KENNEL 0 DAIRY <br /> �T HAZARDous wASTE GENERATOR ❑ CHICKEN RANCH d PKG TREATMENT PLANT <br /> O TIERED PEiti MI3 FACILITY ❑ MOTELMOTEL O PUMPER TRUCKIYARDICHEM TOILETS <br /> O TAlTOOWDY PEIRCING 0 POOUSPA Cl LAND USE APPtICA'CION SITES <br /> 4 MEDK:AL 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 /> Uts appropriate box(es). At least one file type MUST be selected. Fax to (209)464-013$or mail to-the <br /> addreaa incji ted above. <br /> Z EHD will notify the applicant if any EUD files exist. An appointment for review will be Confirmed <br /> approximately five business days but no later than ten (10) days after recelpt 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 wonted an by EHD staff may not be immediately ava9abie 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 ralsased-will be reorganized by EHD staff at the expense, <br /> of the applicant. Future file reviews by the same applicant may require a$76.00 deposit prior to review. <br /> 5. '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 APPOINTMENT DATE TIME — <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEIMED YES NO REVIEW DATE <br />