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04/30/2`003 09:42 FAX 209 9480621 Q)002,003 <br />;4 e}to u>0 roUMBER <br />DATE!IiEDIji, <br />�PUBLIC HEALTH SERGESESA N COUNTY J <br />�- ENVIRONMENTAL HEALTH DIVISION <br />APR 3 0 2003 304 EAST WEBER AVENUE, THIRD FLOOR <br />STOCKTON CA 95202 <br />NVlr(209) 468-3420 <br />�i��;i��l�vl HEAL <br />r,,: c r,r T��FRVI('F UBLlC RECORDS RELEASE APPLICATION <br />/�lti�p /"/�.. BUSINESS/AGENCY /�:n�r1�'.-- -- <br />APPLICANT f - <br />ADDRESS a' .. - - 'r- 'r— -%/- S f- ---- <br />PHONE qq.0" 13 ys FACSIMILE <br />TENTATIVE" APPOINTMENT DATE S <br />(Please give 7 to 10 business days from date of application submittal) Gly <br />CHECK BOX TO EXPEDITE REQUEST .467.00 FEE- REQUEST PROCESSED IN 3 BUSINESS 134YSUI LAyd <br />E OF DATE <br />SIGNATURE APPLICANT��© ry <br />R <br />ENVIRONMENTAL HEALTH DIVISION FILES <br />.UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT DC7 ,Sf�L11J Wa�;TE FACILRY <br />OTHER CLEANUP SITE (NON" -OP) ❑ FOOD FACILITY ,rer souii WAa M VEHICLE <br />..0'GNOERGyROUND TANK (MONrrORINGIREMOVAL) ❑ DOG KENNEL 0 DEJIt I' <br />O HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br />❑ TIERED PERMITTED FACILr1Y ❑ MOTELIHOTEL d PLIMF'ERTRUCWYAROICHEM TOILEr•SI <br />❑ TATTOOIBODY PEIRCING ❑ POOtisINA ®U,NEI usE AF'PuCATION SITES <br />❑ MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM O O'rHF:R (PLEA:>E SPECIFY ABOVE) <br />1. List up to ten addresses in the space above. Select the type(s) of -riles Pram the list above by checking <br />the appropriate box(es). At least one file type MUST be selected.ax to (2,, 09,1464--138 or 11'a"" to 'I'll <br />address indicated above.. <br />2. EHD will notify the applicant if any END files exist. An appointment for rovieW will be Confirmed <br />approximately five business days but no later than ten (10) days after receipt of ;Ipplication. 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 avallable. <br />4. Any file not returned in the same condition as released will be reorganizE�d'b}� EMD staff at the expense <br />of the applicant. Future file reviews by the same applicant may tequime a $87-00 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 busines:s day. <br />CONFIRMED APPOINTMENT DATE TIMEDATE CONFIRMED CONFIRMED PHONE FAX INITIALS <br />REVIEWED YES NO REVIEW DATE: <br />j <br />3 <br />