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lkh <br /> _ EHD LOU NUMULK <br /> DATE RECEIVED �` SAN JOAQUIN COUNTY <br /> EC�Ic �E D ENVIRONMENTAL HEALTH DEPARTVNT <br /> 304 E Weber Ave 3`d Floor Stockton, CA 95205 <br /> JUN 1 7 2004(209)468-3420 Fax: (209)464-0138 Web: WwW.co.san-joaquin.ca.bs/ehd <br /> E4VIR0NP,.1ENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> PERMIT/SERyius <br /> APPLICANT- f"- MI_WG r BUSINESSIAGENCY: <br /> ADDRESS: <br /> PHON d FACSIMILES �vi9"�oa <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUE $93.00 FEE-RE I;ST ROCESSED IN 3 BUSINESS DAYS <br /> DATE <br /> SIGNATURE OF APPLICANT <br /> �z <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> ,- Street .•s �fr. city 't n Unit 1 7 �\ <br /> 2. SVeet G <br /> s. Street a ❑ Unit 2 <br /> 4. Street G <br /> s.. street Unit 3 <br /> S. "Street o <br /> ty <br /> 7. Street aty Unit 4 <br /> a. Stmt a <br /> ty <br /> s sheet oty Unit 5 <br /> 10. street a <br /> ty <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 13 HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) 13 POG KENNEL ❑ DAIRY <br /> UNDERGROUND TANK(M ONITORINGIREM OVAL) ❑ CHICKEN RANCH 13PKG TREATMENT PLANT <br /> HAZARDOUS WASTE GENERATOR ❑ MOTELIHOTEL ❑ PUMPER TRUCKfYARDICHEM TOILETS <br /> TIERED PERMITTED FACILITY ❑ POOUSPA ❑ LAND USE APPLICATION SITES <br /> 0 TATTOOIBODY PIERCING ❑ OTHER(PLEASE SPECIFY) <br /> ❑ MEDICAL WASTE FACILITY <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 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 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 /> TINE <br /> CO.NFiRMED APPOINTMENT DATE <br /> _ s <br /> DATE`COIJFIRMED" <br /> PHONE.:: FAX INITIALS F��� <br /> REVIEWED __ YES NO REVIEW DATE= <br /> ' EHD 46-02-0D6 _ <br /> SIWZ003 <br />