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FAX NO. : 2'095690295 tui. �1 2uUi U .Hll <br /> FR01 ti Geo Phase F�..±},r-orraental - OIDLC eluMl <br /> res 1� Ir � <br /> S JOAQUIN COUNTYPUBLIG HEALTH SER ES <br /> �S ENVIRONMENTAL HEALTH DIVISION ik <br /> JUL 3 1 20 1 <br /> n 304 EAST WEBER AVENUE,THIRD FLOOR <br /> STOCKTON CA 95202 <br /> ENdiii'J'iJ;^[.Id I -c+ (209)468-3420 <br /> I, ;_i, ,i; ;=.;',:•CFS <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> _ � / f�dr� BUSINESSfAGENCY G'��°� <br /> APPLICANT 7 V <br /> ADDRESS <br /> 6 a FACSIMILE <br /> PHONE r/ _ <br /> %� TIME <br /> TENTATIVE'APPOINTMENT DATE �'�' <br /> (Please give 7 l0 1e business bay:from�date of application svhmitWl} <br /> RE REOUEST;Xe FEE—REQUEST PROCESS <br /> 10 CHECK BOx TQ EXPEOel 6W/rL5 EO IN38USINE55 DAYS <br /> A <br /> SIGNATURE Ot APPLICANT <br /> FIi.P ADDRESS O <br /> ,V <br /> I ---- Oq <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> in HOUSING ABATEMENT O SOLID WASTE FACILITY <br /> `UNDERGROUND TANK(UST)CLEANUP SITE(LOP) O FOOD FACWYY ❑ SOLID WASTE VEHICLE <br /> ❑ OTHER CLEANUP SITE(NON-LOP) O DAIRY <br /> UNDERGROUND TANK(MONITORINWREMOVAL) 0 000 <br /> H CKEN RATICH n PKG TREATMENT PLANT <br /> HAZARDOUS WASTE GENERATOR ❑ M KEEN AN ❑ PUMPER TRUCKIYARD108EM TOILETS <br /> ❑ TIERED PERMITTED FACILITY p P00USPA ❑ LAND USE APPLICATION SITES <br /> ❑ TATTOOIBODY pFiRCING ❑ PUBLIC WATER SYSTEM [3 OTHER(PLEASE SPECIFY ABOVE) <br /> ❑ MEDICALWA94EFACILITY <br /> y, List Up t ten addresses in the space above. Select the lypact of Fa'x-from tho list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(2091464-0138 or mail to the <br /> address indicated above- <br /> 2, EHD will notify the applicant if any EHD files exist- An appointment for review will be confirme <br /> approximately will notify <br /> five business days but no later than ten(10)days after receipt of application. The files <br /> will be hold for a maximum of five business days for review. Appointments should be scheduled <br /> accordingly. <br /> 3- A rile 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 availablestaff at the. <br /> a of thfeta notcantr Future file reviews)yitthe same applicant may requion as released will be irleZa $78.00 ed depos t prior t expense <br /> eview. <br /> 5. 'TEf1TATiVE appointment dates must be confirmed with EHD staff. <br /> 5. Applications received after 3:00 pm will be processed the next business day. <br /> rDATE <br /> FIRMED APPOINTMENT DATE TIME <br /> CONFIRMED <br /> PHONE PAX INITIALS <br /> I REVIHWED YES NO REVIEW DATE _. <br /> s co a ov'Laa <br /> l <br />