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)ep. 2. 2UUb IU: 1 IAM No, 2539 P. 1/2 <br /> DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ���'a Telephone: (209)468-3420 Fax: (209)464-0138 Web: WWW.sjgov.or /eh <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT! PNYI(/ �lGy{il.�/ //', BUSINESS/AGENCY: 5 r /Ori <br /> ADDRESS: l✓I W k 1 t � Clty/State/Zip <br /> PHHONE(2): FACSIMILE: <br /> TENTATIVE"APPOINTMENT DATE: xz ZOOS TIIne: A <br /> (Please allow 10 business days from datJ of 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 <br /> Electronic Informat <br /> 4D USE ONLY <br /> Street# -- <br /> r <br /> 1 _ _ __ ___ , ❑ Unit <br /> 2. Z V ✓ . -- -- ❑ Unit <br /> 3. 10 <br /> - - - - <br /> 4. Unit 3 <br /> , <br /> Unit 4 <br /> 6. <br /> 7. =--- - - <br /> ❑ unit S <br /> 9. 0 / <br /> 10. � �'- _ __/.- - -. _ Ll Unit 6 <br /> Specific Date Range of --- - -- <br /> UNDERGROUND TANK(US , -'`- 'ACILITYNEHICLE <br /> OTHER CLEANUP SITE(N( 5 <br /> NDERGROUND TANK(MC------- -- - <br /> AZARDOUS WASTE GENE TREATMENT PLANT <br /> 13 TIERED PERMITTED FACILI - —IYARD/CHEM TOILETS <br /> 13 TATTOO/BODY PIERCING -ICATION SITES <br /> 13 MEDICAL WAsTE FACILITY <br /> WELL AND SEE-- -- - - - - _--- -- - --.- - -- XUDING HOLIDAYS, <br /> 1. List up to ten addre: <br /> At least on---- - - - - acking the appropriate <br /> box(es). <br /> dicated above. Address <br /> ranges will not be a( plications received after <br /> 3:00 pm will be prod <br /> 2, The EHD will notify t ned approximately ten(10) <br /> days after receipt of _ -___---__—_ - eview. Appointments <br /> should be scheduler <br /> 3. A flle that Is actively _. _ 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 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 8/04/08 PUBLIC RECORDS RELEASE APP FORM <br />