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DATE RECEIVED <br /> 1= __•5 EHD LOG NUMBER <br /> SAN.IOAQUIN COUNTY <br /> E,NVkNMENTAL HEALTH DEPARTMW-r <br /> 0[ ( Z 4. 20 �_ 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br /> X09) 468-3420 Fax: (209)464-0138 Web: WWW.co.san joaquin.ca.usNhkI <br /> t-ry i <br /> PUBLIC RECORDS RELEASE APPLICA <br /> APPLICANT: BUSINESS/AGENCY: SC IC V� <br /> ADDRESS:32/c> ( Q e <br /> PHONE: FACSIMILE: d <br /> TENTATIVE"APPOINTMENT DATE: Time: <br /> (Please allow 1D business days from-date of application submittal) <br /> CHECK BOX TO EXPEDITE REQ ST- 3 FE —REQUEST OCI^SSED tN'3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE b <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> Street C BL a - .� L -- <br /> Unit 1 <br /> z. weer � W. ( ci ❑ _ <br /> 3. street I +c. %- LAC . Ci <br /> PA <br /> U VA , 1 <br /> <. sweet .• c ❑ Unit 2l�' <br /> 5. Streer I�1..0 o ' i\ <br /> 9. Street <br /> Co JJ iZ2�y V K tJ V 3 I <br /> 7. Street c;ty <br /> ' <br /> 6. Street Unit 4Ci S <br /> 9. street cityUnit 5 <br /> 10. Street Ci <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> : SXNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> a UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> M-f{AZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> M-f EKED PERMITTED FACILITY ❑ MOTELMOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATrooiBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> "EDICAL WASTE FACILITY ❑ 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. ; - r <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 46-02-006 i <br /> 81812003 <br /> 4 ' <br />