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Se 0'7. 04' 114 1 � <br /> P 5p R p. 1 <br /> EHD LOG NUMBER <br /> DATE RECEIVED <br /> SAN JOAQM COUNTY <br /> �iV [ENTAL HEALTH DEPARTMENT <br /> bVlTeber Ave 3rd Floor Stockton,CA 95205' <br /> ( 3 20 Fax: (209)464-0138 Web: www.co.san-joaquin-cams/elid <br /> =/ PN 4: 1 a I q q <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: 5 etre firer 5� BUSINESSlAGENCY:j,r)2'22! E/V4;wt?ei %4 � - <br /> ADDRESS: �GiL1l S�+LCil1 r� �(/: I 20-z- Q <br /> « :- PHONE: --FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Thne: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Depanment Use OnlY ` <br /> FILE ADDRESS UNIT <br /> i. Sundt 2Z 3 91 7 e 0 ❑ Unit 1 <br /> 3- street c. ❑ �Unit2 <br /> 4. Street G <br /> ty <br /> AL <br /> s. street c U 1t 112).. <br /> S. Sweet C6 <br /> 7. SOW Ck llff <br /> B. Street C <br /> hy <br /> 9. street 0fty ❑ Unit 5 <br /> 10. Street Cl - <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 13 HOUSING ABATEMENT ❑ SOLID WASTE FACILnY <br /> OTHER CLEANUP SrrE(NON-LOP) 0 FOOD FACILITY d SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL 0 DAIRY <br /> HAZARDOUS WASTE GENERATOR CI CHICKEN RANCH E3PKG TREATMENT PLANT ,;- <br /> ❑ TIERED PERMITTED FACILrrY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> 13 TATTOOIBODY PIERCING ❑ POOLISPA ❑ 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(2091464-0138 ar'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 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 applicant may-require a$93.00 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 INMALS <br /> REVIEWED YES NO REVIEW DATE <br /> 6F0 43d2496 <br /> N82603 <br />