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209d6i1 ASE STCC.XT3H PAGE 02 <br /> SAN J UIN COUNTYPUBLIC HEALTH SICES <br /> ENVIRONMENTAL HEALTH DIVISIO <br /> OCT 1 8 2000 304 EAST WEBER AVENUE, THIRD FLOOR <br /> STOCKTON CA 95202 <br /> (209) 468-3420 <br /> _NVIRONMENT HEALTH PURL C RECORDS RELEASE APPLICATION <br /> APPLICANT 1/J BUSINESSIAGENCY Ql�l/Clj7LP� l'l�C�'l U/�^D�m�� t + �C• <br /> ADDRESS L160s I _U2 o a 7 CA saos- <br /> PHONE a D /�FAC{{SIMILE <br /> TENTATIVE'APPOINTMEN DATE C)IL�•� TIME <br /> r-•-t (Pleas give 7 to 10 business days from date of application subrriml) <br /> u CHECK BOX TO EXPEDITE REOUES •578.0 EE—RE EST PROCESSED IN 3 9USfNESS DAYS <br /> SIGNATURE OF APPLICANT DATE ,ZO�D <br /> FILE ADDRESS <br /> o 'Z & <br /> --r - <br /> I - <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> ? O SOUL)WASTE FACILITY UNDERGROUND TANK(UST)CLEAN P SITE (LOP) ❑ HOUSING ABATEMENT [DSOLID WASTE VEHICLE <br /> K OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY <br /> HI CKENNELRA b DAIRY <br /> 7 UNDERGROUND TANK(MONITORING REMOVAL) 13o FKG TREATMENT PLANT <br /> IR HAZARDOUS WASTE GENERATOR I] CHICKEN NGFI <br /> ❑ TIERED PER/tFTED FACILITY ❑ POTEUHOTEL 13 PUMP ERTRUCSE LICATION SITES TOILETS <br /> ❑ TATTOOIBODY PEIRCING ❑ PUBLIC W ❑ LAND (PLEASLICATI IF SITES <br /> ❑ MEDICAL WASTE FACIl1TY ❑ PUBLIC WATER SYSTEM ❑ OTHER (PLEASE SPECIFY ADDVE) <br /> 1• List up to ten addresses in the space above- Select the type(s) of files from the Ilst above by checking <br /> the appropriate boxes At least one file type MUST be selected. Fax to(209) 464-0138 or mpil to the <br /> address indi ted a P y Intment for review will be confirmed <br /> 2, EHD will not( thea cant if an EHA tiles exist. An appo <br /> approximately five bus ,less days but no later than ten (10) days after receipt of application. The files <br /> will be held for a maXin um of five business days for review. Appointments should be scheduled <br /> accordingly. <br /> 3. A file that is act(vely b ing worked on by EHD staff may not be immediately available for review. A new <br /> application may be su mitted when the file is available. <br /> 4, Any file not returned ir the same condition as released will be reorganized by EHD staff at the expense <br /> of the applicant. Futur file reviews by the same applicant may require a 578.00 deposit prior to review. <br /> 5, `TENTATIVE appointor nt dates most be confirmed with EHD staff. <br /> 6. Applications received fter 3:00 pm will be processed the next business day. <br /> f CONFIRMED APPOINTMENT 3ATE TIME <br /> DATE <br /> CONFIRMED PHONE FAX INITIALS <br /> REVIEW DATE <br /> REVIEWED YES NO <br /> EM 40 t{ e1pAU0 <br />