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DATE RECEIVED <br />"r Fr ' AN JOAQUIN COUNTY <br />SEHD LOG NUMBER <br />E1v oNMENTAL HEALTH DErARTM:NT <br />S E P 1 2 20 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br />09) 468-3420 Fax: (209) 464-0138 Web: www-co.sanjoaquin.ca.us/ehd <br />'=4v HONMENT HEALTH <br />PCRMIT/SERVICES ^PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: Q 0" BUSINESSIAGENCY: C C r �a: l 1 `-, T i c <br />ADDRESS: -lee FTI -1 l ' Ve S• % (!f I^ . 5TT LE <br />A <br />(� I n 2 _ <br />PHONE:- Z o % Z3 I Q S 1 FACSIMILE: ZO `t L 3 q Q J S <br />r� <br />TENTATIVE" APPOINTMENT DATE: W c� �GD % � D j'�a3 <br />Time: <br />(Please allow 10 business days from date of application submittal) <br />El CHECK BOX TO EXPEDITE REQUEST - 93.00 FEE - REQUEST PROC SSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />� 11NDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />®' THER CLEANUP SITE (NON -LOP) <br />UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ HAZARDOUS WASTE GENERATOR <br />❑ TIERED PERMITTED FACILITY <br />❑ TATTOO/BODY PIERCING <br />❑ MEDICAL WASTE FACILITY <br />Department Use Only <br />C> <br />UNIT <br />❑ Unit 1 <br />❑ Unit 2 <br />�� J <br />VUnit <br />Unit 4 <br />❑ Unit 5 <br />US64 <br />HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br />FOOD FACILITY ❑ SOLID WASTE VEHICLE <br />DOG KENNEL ❑ DAIRY to <br />CHICKEN RANCH ❑ PKG TREATMENT PLANT <br />MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br />POOL/SPA ❑ LAND USE APPLICATION SITES <br />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) 464-0138 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 will be processed the next business dayco <br />Z.0'ONFIRMED APPOINTMENT DATE TM4 <br />DATE CONFIRMED <br />REVIEWED YES NO <br />8,=oa3���� .7i'l ; <br />�6� L <br />PHONE . FAX INITIALS <br />REVIEW DATE <br />iIA s ;� s 7�o r 7'� /Y) lit D C �� rrr I tb Pr <br />