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✓ 10/14/2004 2094,753433 FIFTH FLOOR y r el <br /> DATE RECENEO ENO LOG WOER <br /> SAN JOAQUJN COUNTY <br /> J <br /> ElvwRQNMENTAL nEA LTH DFEPARTMENT <br /> 304 E Webcr Ave 3"4 Floor Stockton,CA,95205 <br /> DEC 1 5 41-b§)469-3420 Far: (209)464-0138 Web:ww-w.co.san-joaquirLmus/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> :'n��lf•-t' <br /> 15r <br /> APPLICANT: l { SUSMSSIAGENCY: �+, <br /> -ADDRESS,- �] ( ` n P IN /2 s (/-W 6 L <br /> PtIONE: 2 ` I Z Lc FACSIMILE: 2-7 <br /> ( <br /> TENTATIVE-APPomrmENT DATE: rune 8 D <br /> (Please Alla w to busincs3 days from Q to of appricatlon svbamirml) <br /> 9CMCK BOX To EXPEDITE RZQUES FEE– EST PR 3 BU FSS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> [kipanminnt Use Only <br /> FILE ADDRESS UNrr <br /> chv ❑ Unit 1 <br /> i Stroa C ❑ Unh 2 <br /> ON Unit 3 •�,U�f/" <br /> Unit <br /> 0. std <br /> a ❑ Unit 5 <br /> 10. stroct a <br /> ENVIRONMENTAL HEALTH vEPARTMENT FILES <br /> UNDERGROUND TANK(usY)c Lr,&NUP srrE(LOP) ❑ HOMING AGA'TEMENT ❑ SOLID WASTE p SOLID WASTE <br /> F <br /> F jq <br /> VIt it <br /> ❑ OTHER CLEANUP SrM(NON-LOP) rI POMFACILnY <br /> KG PT <br /> br umogRaWUND TANK(MONITORINGIREMOVAL) El DOG IC0N�lEL ❑ <br /> O HAZARDOUS WASTE GENRIZATOR G c44CKEN RANCH 0TfG TREATMENT PLAN <br /> RDO <br /> D TIERED PERMMIED FACOMY ❑ MAOTEUHOTE1., Q PUMPER TRUCK/YARDICHEM TOILETS <br /> O TATTOO/BODYPII:RCINQ POOl1SPA nG�WdDUSE APPLICATION SMq <br /> 173 MEnICALWASTE FACRIN OTHER(PLLASE SPECIFY) 0Aex-yx —' <br /> 7_ List up to ten addresses in the space above. Select the,type(s)of files from the list aboye py checking <br /> the approprlate box(es). At least one file type MUST be selected. Fax to 209 464-0'1313 Pr M;Rll to the <br /> address Indicated ats6ve_ <br /> 2_ EHD Vail notify the applicant If any EHD files exist An appointment for review will be confirmed <br /> sfproximatoly 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 fl®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 reorganl2ed by EHD staff at the expense <br /> of the applicant. Future file reviews by the tame applicant may require a$93.00 deposit prior to review- <br /> '5- <br /> eview.'5_ 'TENTATri/E.appointment dotes must be confirmed with EHD staff. <br /> 6. Applications received after 3:00 pm will be processed the zwxt business day. <br /> ExoIN�1141i"! ?T•D ; j 2 •:y '�`?«' c : .w <br /> �E �;�`"' �� .;.,.•� •TIME :��i-�.•F,..�: <br /> E COt�F�fZK+IhD .'r!T1t6NE :� FAX,. <br /> _ 4 � <br /> 'I`ti.YIEWED 'h S NO RMEWI DATE �' !• . y r <br /> wloos - <br /> 000 2I0035 S01STLZ699 YVd TZ:LT Q3& 1'0/9T/ZT <br />