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[N[1 LOG NUMDER DATE RECEIVtO SAN JOAAN COUNTYPUELIC HEALTH SEOICES ENVIRONMENTAL HEALTH DIVISION K" 6 iF: I( 304 EAST WEBER AVENUE, THIRD FLOOR +/q0j STOGKTON CA 95202 /"/l l V 1 (209)468-3420 W PUBLIC RECORDS RELEASE APPLICATION APR x900 4 ` {�� 2� TVAC �i•;?/aI..I EALTH l--l�titl� t`�-( BUSINESS/AGENCY r� r-r•.,nr r^ APPLICANT q p L ,5 X10 ADDRESS PHONE __ 11 O" -�,t3dt� FACSIMILE � TENTATIVE" APPOINTMENT DATE 22- 19-000 TIME (Please give 7 to 10 business days from date of application submittal) I �y�lyl CHECK BOX TO EXPEDITE REQUEST $78.00 FEE — R EST PROCESSED IN 3 BUSINESS DAYS SIGN U E OF APPLICANT DATE � d FILE D SS .--• I Ve-4UA 0-- 0 If lQ p -) o L Even (�► St . r k� "C . 3s � iF i t.� - E leve -,-4 St . i r . s e c,�e.�- j�j (' 1a_ e ie,yc��1_ fi T a 2 I ZZ Z33 "l qC.�� el .fir �3`.. cC) . L ► I c°C10 ei 1'. A I ENVIRONMENTAL HEALTH dIVISION FILES �Z XsOUD WASTE FACILITY ❑ SOLID WASTE VEHICL>APR 24 { " ❑ DAIRY ❑ PKG TREATMENT PLANT ❑ PUMPER TRUCK/YARD/CHEM TOILETS ❑ LAND USE APPLICATION SITES ❑ OTHER (PLEASE SPECIFY ABOVE) 1, List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the' addre s indicated above, 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately five business days but no later than ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by END staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned in the same condition as released will be reorganized by END staff at the expense of the applicant. Future file reviews by the same applicant may require a $78.00 deposit prior to review. 5. "TENTATIVE appointment dates must be confirmed with EHD staff. 6. Applications receive esSed the next business day. o/o0 ®o.1Oto Y'e>1I1--0e.d �Lstr`b ecQ vvto�• CONFIRMED APPOINTMENT DATE TIME DATE CONFIRMED PHONE FAX INITIALS REVIEWED YES NO REVIEW DATE EN QO da01/0 4 f Z 'Se .OQ al�i� TOTAL P.02 04 UNDERGROUND TANK (UST) CLEANUP SITE (LOP) O HOUSING ABATEMENT OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY UNDERGROUND TANK (MONITORINGIREMOVAL) O DOG KENNEL HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL O TATTOO/BODY PEIRCING d ❑ POOUSPA PUBLIC WATER SYSTEM O MEDICAL WASTE FACILITY �Z XsOUD WASTE FACILITY ❑ SOLID WASTE VEHICL>APR 24 { " ❑ DAIRY ❑ PKG TREATMENT PLANT ❑ PUMPER TRUCK/YARD/CHEM TOILETS ❑ LAND USE APPLICATION SITES ❑ OTHER (PLEASE SPECIFY ABOVE) 1, List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the' addre s indicated above, 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately five business days but no later than ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by END staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned in the same condition as released will be reorganized by END staff at the expense of the applicant. Future file reviews by the same applicant may require a $78.00 deposit prior to review. 5. "TENTATIVE appointment dates must be confirmed with EHD staff. 6. Applications receive esSed the next business day. o/o0 ®o.1Oto Y'e>1I1--0e.d �Lstr`b ecQ vvto�• CONFIRMED APPOINTMENT DATE TIME DATE CONFIRMED PHONE FAX INITIALS REVIEWED YES NO REVIEW DATE EN QO da01/0 4 f Z 'Se .OQ al�i� TOTAL P.02