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SAN UIN COUNiYPUBLIC HEALTH S�y�� 5 1(w NJMLLN <br /> 1RONMENTAL HEALTH DIVISION <br /> 04 EAST WESERAVENUE,THIRD FLOOR <br /> STOCKTON CA 95202i (209) 468-3420 <br /> ( <br /> I'USLI REGORDSeRELEASE APPLICATION J / <br /> APPLICANT DRESS _.IEAN FIN 8UMNESSIAGENCY_SECV& TN Thom Ann i <br /> ADDRESS 2 t }L, � •.. N fF- �nc p <br /> 102 <br /> PHONE U Z <br /> �ZS - 3-/ - (App FACSIMILE <br /> TENTATIVE'APPOWTMENT; ATE 5TIM <br /> (P104s0 Vivo 7 to 1 eeu ji ss days from daW of`,ep'pliopNpn>a�b�ta00 R <br /> CHECK BOK TO EXPEDITE REQUEST:$y7Ae FEP_7tE EST 314 <br /> PROCESSED IN 4 BUSINESS DAYS �'---- <br /> SIGNATURE OFAPPLICANT <br /> �> DATE S 72�� I <br /> FILE ADDAE 9 TF1t9 BIDE EHO STAFF USE ONLY <br /> 10't <br /> PROGRAM ELEMENTS SEARCH <br /> cr i n . o7g•$a <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> B3'UNOERGROUNO TANK(UST)CLEANUP SITE(LOP) ❑ HOUSINF ABATEMENT ❑ SOLID WASTE FACILITY <br /> m`oTHERCLEANUP SITE(NON-LOPS I � ❑ FOOD FACILITY <br /> W'UNDERGROUND TANK(MONITORINcJRt MOV ❑ SOLID WASTE VEHICLE <br /> 4KHAZARDOUS WASTE GENERATOR 0 OOO KENNEL ❑ DAIRY <br /> 53"TLERED PERMITTED FACILITYn CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> O TATTOOIBOPYPEIRCING ❑ MOTEUHDTEL ❑ PUMPER 7RUCKrTAAprCHEhi701LiT5 <br /> ❑ <br /> MEDICAL.WASTE FACILITY PUBLAC WATER SYSTEM O LAND USE APPLICATION SITES <br /> �❑ PUBLLC WC7 OTHER(PLEASE SPECIFY A80VE) <br /> t. List up to Inn addresses !n the spats above_ Select the types)Of flies from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(20914 <br /> address Indicated abe s4-0138 or trrail tw thg <br /> z• EHD will notify the applic*t if any EHD files exist. An appointment for review Will be confirmed <br /> approximately five businuhs days but no later than ten(10)days after recolpt of applicat(on. The files <br /> Will beheld for a maximuM of five business days for review. Appointments should be scheduled <br /> accordingly. <br /> 3- A file that is actively belnd worked on by EHD staff may not be immediately available for review. A new . <br /> application may be submitted when the file Is avallable. <br /> 4- Any file not returned in the same condition as released will be reorganized by EHD staff at the expense <br /> of the appf!CanL Futuro file reviews by the same applicant may require a 487.00 deposit prior tc review. <br /> 5; "TENTATIVE appointment dates must be confirmed with EHD staff. <br /> S• Applications received atter 3:00 Pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE <br /> TIME <br /> DATE CONFIRMED PHONE FAX <br /> INITIALS <br /> ,REVIEWED YES f <br /> en �0 1� .NO REVIEW DATE <br /> TOTRL P.01 <br />