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04/30/2003 09:42 FAX 209 9480621 10002.003 <br />:L..D ElVED-i .-� C_ i''ti\.. / r -1•• EHO Lr>Q NUMBER <br />AOIN COUNTYPUBLIC HEALTH SEP0-I~S <br />LTH DIVISION <br />APR302003 <br />,`NVIRI: j \lM'1 l HEAL <br />c�-r, rn�TrCFR\ll(�FS <br />ENVIRONMENTAL HEA <br />304 EAST WEBER AVENUE, THIRD FLOOR <br />STOCKTON CA 95202 <br />(209) 468-3420 <br />I3ILIC RECORDS RELEASE APPLICATION <br />APPLICANT <br />�' ! - ✓'Ti4 BUSINESSIAGENCY Ac -e r 1 'r, <br />ADDRESS .`�� <br />PHONE �3 yS FACSIMILE- <br />_ /r <br />TENTATIVE" APPOINTMENT DATE S / 7/ <br />C-- 2-- TIME / <br />(Please give T to 10 business days from date of application submittal) <br />CHECK BOX TO EXPEDITE REQUEST - S87.00 FEE- REQUEST PROCESSED IN 3 BUSINt3e55 DAYS <br />SIGNATURE OF APPLiCANT R <br />DATE _ c7 '940 ill <br />FILE <br />'7—/,R76 Covv+sr Clvb <br />%*, 19 S*eo CtSv. i-% --y C/v& <br />-PIIS Slat: EHD STAFF USE VI's LT <br />PROGRF.MMELEKENTS SEARCH <br />�_T _ W <br />\J <br />81vt- <br />'- • <br />;Xr o 3 �.,- cry, �r�� <br />_ <br />+v <br />/yd 3 Cov^+..- ClVb 131✓Z <br />P.57 5CGtlif fr • C/v6 � I✓L <br />� <br />I/ <br />;270 r, Cow., C l u b J31 v� <br />► ^� �` <br />C 0L , 4-►- 00-4 vb 131 v L- <br />ENVIRONMENTAL HEALTH DIVISION FiLES <br />-0-UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING A13ATEMENT <br />0 )Lw WA,:iTI: FACILrY <br />oun wA:STE Yl HiCLE <br />OTHER CLEANUP SITE (NON -LOP) <br />C3 FOOD FACILITY <br />10-15- <br />0 DAIRY <br />.Ia NDERGROUND TANK (MONirORINGIREMOVAL) <br />O DOG KENNEL <br />❑ PKG •TREATMENT PLANT <br />O HAZARDOUS WASTE GENERATOR <br />0 CHICKEN RANCH <br />0 PUMF'ERTRUCWYARDICHEM TOILET•5 <br />❑ TTERED PERMITTED FACILIiY <br />❑ MOTELIHOTEL <br />❑ POOLIShA " ' <br />❑ L1,ND USE APPLICATION SITU" <br />0 TATTOOIBODY PEIRCING <br />O MEDICAL WASTE FACILITY <br />0 PUBLIC WATER SYSTEM <br />0 OTFiF:R (PI.EA.1>E SPECIFY f,i30VE) <br />1. List up to ten addresses in the space above. Select the type(s) of files frarn the list above by checking <br />the appropriate box(es). At least one file type MUST be selected, fax i:4 r,209j 464-C►138 or mail to the <br />address indicated above.. <br />2. EHD will notify the applicant if any EHD files exist. An appointment for rovievtr will be confirmed <br />approximately five business days but no later than ten (10) days after teczipt 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 immediate►ly available for reiriew. A new <br />application may be submitted when the tile is available. <br />4. Any file not returned in the same condition as released will be reorganize d bye EHD staff at the expense <br />of the applicant. Future file reviews by the same applicant may requim 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 busine:4s day. <br />CONFIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX INITIALS <br />REVIEWED <br />YVA mn <br />REVIEW DATE <br />