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_Sep 02 05 09:349 pi. 408 -1224 p.1 <br />low <br />d <br />& tVEHD LOG NUMBER <br />SAN JoAQvnv COUNTY <br />SEP - 2 2005 ENv]RONMENTAL HEALTH DEPARTMENT <br />304 FWeber Ave 3`d Floor Stockton, CA 95205 <br />ENVIRONMENT HAff)1 68-3420 Fax: (209) 464-0138 Web: www.co,san-joaquin.cams/ehd <br />PERMIT/SERVICES <br />PUBLICInRE/jCORDS RELEASE APPLICATION <br />APPLICANT: C/C/�r" 1 BUSINESSIAGENCY: <br />ADDRESS: <br />PHONE: FACSIMILE: <br />TENTATIVE* APPOINTMENT DATE: Time: " <br />(Please allow 10 business days from date of application submittal) (rye (��{r}A�►y",fin'{` D <br />CHECK BOX TO EXPEDITE REQUEST • $93 00 kEE —REQUEST PROCESSED IN 3 BUSINESS DAYS Ij1►Vn') ►UI (�+�f�J� <br />� D <br />SIGNATURE OF APPLICANT "'�l wy "�r/ v L YV DATE Z <br />Department Use Only <br />UNIT <br />❑ Unit 1 <br />❑ Unit 2 A o <br />Unik 3 <br />nit 4 <br />❑ Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />.421 UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />❑ SOLID WASTE FACILITY <br />-Z'OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />❑ SOLID WASTE VEHICLE <br />-."UNDERGROUND TANK (MON[TORINGIREMOVAL) <br />0 DOG KENNEL <br />d DAIRY <br />�AZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ PKG TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY <br />❑ MOTELIHOTEL <br />❑ PUMPER TRUCKIYARD/CHEM TOILETS <br />❑ TATTOOIBODY PIERCING <br />0 POOL/SPA <br />❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY <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 />S. *TENTATIVE appointment dates must be confirmed with EHD staff. <br />6. Applications received after 3:00 pm will be processed the next business day. <br />CONFIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX INITIALS <br />REVIEWED YES NO REVIEW DATE <br />EHO 4a -02 -DOG <br />8/82009 <br />E ) <br />�J <br />