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DATE RECEIVEDEHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E Weber Ave 3rd Floor Stockton, CA 95245 <br /> (209) 468-3420 Fax: (209) 464-0138 Web: www.co.san.joaquin.ca.us/ehd' <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: v BUSINESSIAGENCY: <br /> ADDRESS: <br /> 3 s, ,e_,� <br /> PHONE: 7 /00 6n FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <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 DAYSI' <br /> SIGNATURE OF APPLICANT x DATE 0.1 Z(O--Q L <br /> �— <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> 1. Street C <br /> ❑ Unit 1 I <br /> 2. Street aty <br /> 3. Streel a <br /> ❑ Unit 2 <br /> 4, Streei City <br /> 5, Street city ❑ Unit 3 k <br /> 6, Street 'h atyi <br /> 7. Street city Unit 4 ,.. <br /> 0, Streel Ci 1 - 1 <br /> 9. Street aty Unit 5 <br /> 10. Street city <br /> i <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑ UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> ❑ OTHER CLEANUP SITE(NON-LOP) ❑ FOOL]FACILITY ❑ SOLID WASTE VEHICLE <br /> ❑ UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY " <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT :i <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL' ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> -❑: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 209 4114-0138 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 wi, 'be pryces ed the next business day. <br /> `.CONFIRMED APPOINTMENT DATE TIME <br /> - <br /> 74 <br /> ;DATE CONFIRMED =r '.PHONE FAX INiS.IA <br /> 4 <br /> -REVIEWEDYES NO REVIEW DATE <br /> EHD 4"2-005 - <br /> &8l2003 <br /> F i <br />