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` EIVED EHD LOG NUMBER <br />a SAN JOAQUIN COUNTY <br />ENVJNMENTAL HEALTH 6EPART41,P_NT <br />S �{p 1 ?2003 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br />(209) 46873420 Fax: (209) 464-0138 Web: www.co.san joaquin.ca.us/ehd <br />'1 VIRONNAENT HEALTH ' <br />qq q <br />FERMI /SERVICES PUBLIC RECORDS RELEASE APPLICATIIO�yN <br />APPLICANT: l t'�((a �PSYJh BUSING /AGENCY: "� • S lot <br />��__f <br />ADDRESS: <br />PHONE: q(� ✓b �=4 7 1 Z FACSIMILE: l ((e 5W - `4-7t S7 <br />TENTATIVE" APPOINTMENT DATE: _ Zai Time: (0 � <br />(Please allow 10 business days from date of application submittal) <br />0 CHECK BOX TO EXPEDITE REQUEST -$93.00 FEE <br />�-REQUEST PROCESSED IN 3 BUSINES DAY <br />SIGNATURE OF APPLICANT ��"/ �� - �' DATE <br />SEP 1 7 E61RONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />tRZ OTHER CLEANUP SITE (NON -LOP) <br />� UNDERGROUND TANK (MONITORING/REMOVAL) <br />1XHAZARDOUS WASTE GENERATOR <br />'TIERED PERMITTED FACILITY <br />❑ TATTOO/BODY PIERCING <br />❑ MEDICAL WASTE FACILITY <br />Department Use Only <br />UNIT <br />_FILE <br />Unit 1 <br />ADDRESS <br />Unit 2 <br />�AUnit <br />❑ <br />-� <br />Unit 4 <br />iA <br />WON, <br />CHICKEN RANCH <br />❑ <br />PKG TREATMENT PLANT <br />❑ <br />MOTELIHOTEL <br />❑ <br />PUMPER TRUCK/YARD/CHEM TOILETS <br />TTRT110 <br />POOUSPA <br />USE APPLICATION SITES <br />❑ <br />4. <br />Street <br />, ly)a <br />city <br />flu <br />nill <br />i rIiIL84 �cu10.- <br />.. <br />t, <br />u1irrfl��I"� <br />ALN® <br />Street <br />citya <br />SEP 1 7 E61RONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />tRZ OTHER CLEANUP SITE (NON -LOP) <br />� UNDERGROUND TANK (MONITORING/REMOVAL) <br />1XHAZARDOUS WASTE GENERATOR <br />'TIERED PERMITTED FACILITY <br />❑ TATTOO/BODY PIERCING <br />❑ MEDICAL WASTE FACILITY <br />Department Use Only <br />UNIT <br />HOUSING ABATEMENT <br />Unit 1 <br />❑ <br />Unit 2 <br />�AUnit <br />❑ <br />-� <br />Unit 4 <br />❑ <br />Unit 5 <br />❑ <br />HOUSING ABATEMENT <br />❑ SOLID WASTE FACILITY <br />A -FOOD FACILITY <br />❑ <br />SOLID WASTE VEHICLE <br />❑ <br />DOG KENNEL <br />❑ <br />DAIRY <br />❑ <br />CHICKEN RANCH <br />❑ <br />PKG TREATMENT PLANT <br />❑ <br />MOTELIHOTEL <br />❑ <br />PUMPER TRUCK/YARD/CHEM TOILETS <br />❑ <br />POOUSPA <br />USE APPLICATION SITES <br />❑ <br />OTHER (PLEASE SPECIFY) <br />C ni <br />, ly)a <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 day. <br />CONFIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX INITIALS <br />REVIEWED YES NO REVIEW DATE <br />EHD 48.02-006 <br />8/8/2003 <br />