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Jep. L. LUUd IU;IIAIV <br />DATE RECEIVED <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 Fast Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.or <br />PUBLIC RECORDS RELEASE APPLICATION <br />No, 2539 P. 1!2 <br />EHD LOG NUMBER <br />' M0,01,09w, <br />TENTATIVE` APPOINTMENT DATE: r ;?7- � 206 Thne: qa N'1 <br />(Please allow 10 business days from datJof application submittal -"Tentative only - must be confirmed) <br />CHECK BOX TO EXPEDITE REQUEST - $105 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT %L1 <br />,e8 <br />Informat <br />�D USE ONLY <br />street tI - �„ -- <br />1. Unit 1 <br />— p Unit 2 <br />3. <br />4. - -- Unit3 <br />6. Unit4 � <br />8. C1C L1 Unit 5 <br />TO 7 <br />10. p / - - ❑ Unit s <br />Specific Date Range of - <br />UNDERGROUND TANK (U5 - l ACILITYNEHICLE <br />OTHER CLEANUP SITE (N( <br />( <br />NDERGROUNDTANK (MC - ------ — <br />AZARDOUS WASTE GEN[ <br />TREATMENT PLANT <br />171 TIERED PERMITTED FACILI _ ..- --. - ----- <br />--- --- -]YARD/CHEM TOILETS <br />TATTOO/BODY PIERCING <br />-KATION SITES <br />MEDICAL WASTE FACILITY <br />WELLANDSEF - -. --... -..- - _.. -- __ -- _ - _- - <br />- 7LUDING HOLIDAYS. <br />1. List up to ten addre: <br />_ __)cking the appropriate <br />box(es). At least on - - <br />dicated above. Address <br />ranges will not be ac <br />plications received after <br />3:00 pm will be proc <br />2. The EHD will notify t <br />ned approximately ten (10) <br />days after receipt of _ <br />----evlew. Appointments <br />should be schadulac - <br />3. A file that Is actively <br />_._ A new application may be <br />submitted when the - - --- <br />4. Any file not returned In the same condition as released will be reorganized by EHD staff at <br />the expense of the applicant - <br />Future file reviews by the same applicant may require a $105 deposit prior to review. <br />EHD USE ONLY <br />EHD 48-06 —8/04108—'— <br />PUBLIC RECORDS RELEASE APP FORM <br />