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Etta LOG NUMBER-/ <br /> part iiCC;E:JEq <br /> /SAN JOAQUIN COUNTYPUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,THIRD FLOOR <br /> r STOCKTON CA 95202 <br /> (209) 468-3420 <br /> v PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT RE BUSINESS(AGENCY � -�^ r A <br /> CA <br /> ADDRESS <br /> ` c' <br /> PHONE �� r� j _--FACSIMILE <br /> ono NY <br /> TE 4TATIVE*APPOINTMENT DATE \` TIME <br /> (Plea5t3 gine 7 to 10 business clAys from date of applitat+Qn Bubmittal) <br /> IT/CHECK BOX TO EXPEDITE RF0UES - FEE—REQUEST PROCESSFD IN 3 BUSINESS DAYS <br /> SIGNATURE(( OFAPPLICANT DATE <br /> C VlC1 cj <br /> LA 1 0OR£s3 n , <br /> t til <br /> 14 <br /> ,� Ott •,tr�c <br /> M vt <br /> Mcx>, <br /> Csy TPt i <br /> 5Z t tGE'�v:3fiY 3 � t.�At�� ifLa <br /> 1n 1 ENVIRONMENTAL HEALTH DIVISION FILES �T <br /> 1 <br /> ❑ NDERGRC UN TANK(UST)CLEANUP SITE{LOP} 11 HOUSING ABATEMENT ❑ SOLID WASTE FACILITY` <br /> ❑ SOLID WASTE VEHICLE <br /> 0CHER CLEANUP SITE(NON4-OP) I ❑ FOOD FACILITY <br /> ❑ DOG KENNEL 11DAIRY <br /> 0 UNDERGROUND TANK(MONITORINGIREM0VAL) ❑ CHICKEN RANCH ❑ PKG TREATMENT PLAW <br /> ❑ RAZARDOLS WASTE GENERATOR n MOTELIHOTEL Q PUMPER TRUCK(YARD/CHFM TOILETS <br /> ❑ TIERED PERMITTED r-ACILITY d POOL&PA ❑ LAND USE APPLICATION SITES <br /> ❑ TATTOOfBODY PEIRGING ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> ❑ MEDICAL WASTE FACILITY <br /> 1. Li:;t up to ten addresses in the space above. Select the type($) of files from the fist above by checking <br /> th1)appropriate boxes). At least one file type MUST be refected. Fax to (2091 <br /> 4 4.0138 or mail to the <br /> address indicated above• <br /> 2, i=t-'�D will notify the applicant if any EHD fifes exist. An appointment for review will be confirmed <br /> er than ten(10) days after receipt of application. The files <br /> approximately five business days but no lat <br /> wi I be hold for a maximum of five business days for review. Appointments should be scheduled <br /> accordingly. vallable for review. A new <br /> 3. <br /> ccordingly- <br /> 3_ A 'ile that is actively being worked on by EHO staff may not be immediately available for review. Anew <br /> appliCation may be submitted when the file is available. <br /> condition as released will be reorganized by EHD staff at the expense <br /> 4. Ar y fife not returned in the same <br /> of the applicant. Future fife raviews by the same applic2lnt may require a $T8.00 deposit prior to review. <br /> 5. *T--7NTATIVE appointment dates must be confirmed with EHD staff. <br /> g_ Applications received after 3:00 pm wlli be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED -- <br /> PHONE FAX INITIALS <br /> 1 <br /> REVIEWED YES NO REVIEW DATE -- <br /> eH as t4 Omui a <br /> T13 SJDVJIJ13?TES8=,L1�. Uti :ZC1 92C��,r'�E/ZL <br />