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UATE M1E{.klYeu n <br /> sAfvJQDIVISIONCES <br /> ENVIRONMENTAL HEALTH <br /> 304 EAST WEBER AVENUE,THIRD FLOOR <br /> 1 1 2�0� STOCKTON CA 95202 ��✓JJ <br /> DEC (209) 468-3420 <br /> IRONi:1EN <br /> - HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> IF 'rL.' r�Sod BUSINESS/AGENCY <br /> APPLCANT/LIQ <br /> 1-IENDf,Q L., Cp �J Sa/OSS <br /> ADDRESS -7Q .� /ll• w ( SO a <br /> PHONE �d – QQ FACSIMILE <br /> TENTATIVE`APPOINTMENT DATE TIME <br /> (Please give 7 to 10 business days tram data Of aPplicaten subminal) <br /> 13 CHECK BOX TO EXPEDITE REQUEST•$78.00 FEE–RE VEST PR CESSED IN 3 BUSINESS DAYS <br /> II <br /> SIGNATURE OF APPLICANT �,,,r�_s- ` .—.. DATE <br /> FILE APPRESS <br /> r atr+t w r a-9s3 <br /> I <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> r] HOUSING ABATEMENT O SOLID WASTE FACILITY <br /> 'f0 UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ FOOD FACILITY 0 SOLID WASTE VEHICLE <br /> ❑ OTHER CLEANUP SITE(NON-LOP) ❑ POG KENNEL 13 DAIRY <br /> 0 UNDERGROUND TANK(MONITORINGIREMOVAL) 0 CHICKEN RANCH EIPKG TREATMENT PLANT <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ MOTEUHOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ TIERED PERMITTED FACILITY ❑ POOUSPA 0 LAND USE APPLICATION SITES <br /> 0 TATTOGOODY PEIRCING p PUBLIC WATER SYSTEM 0 OTHER(PLEASE SPECIFY ABOVE) <br /> ❑ MEDICAL WASTE FACILITY <br /> 1. List up to ten addresses in tha 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 (2091404-0198 or mail to the <br /> address Lagmated above. ointment for review will be confirmed <br /> 2. EHD will notify the applicant it y EHD files exist. An appointment t of a Ilcation. The flees <br /> approximately five business days but no later than len(10)da s after receip pp <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 /> III be reorganized by EHD staff at the 4. Any file not returned in the same condition as released cant may require a$78.0 deposit prior to review.applicant. Future file reviews by the same app' <br /> 5, "TENTATIVE appointment dales 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 <br /> PHONE FAX =INITIALI � <br /> REVIEWED YES NO REVIEW DATE <br /> EX DON OiN'�O <br />