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EHD LOG NUMBER � <br /> DATE RECEIVED { SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> NECED <br /> 304 E Weber Ave 3 Floor Stockton,CA 95205 <br /> J U 2) 468-3420 Fax: (209)464-0138 Web:b: <br /> joaquin.ca.uslehd <br /> ENVIRONMENT HEALTH pUBLIC RECORDS RELEASE APPLICATION � <br /> APPLICANT: �R y BUSINESSIAGENCY: <br /> ADDRESS: <br /> PHONE: old $ 2 I! FACSIMILE: s�O 9 $ 2 O — <br /> q [c��c Time: <br /> TENTATIVE*APPOINTME DATE: <br /> (Please allow 10 business days from date of application submittal) <br /> I <br /> i <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE–REQUEST PROCESS? D 3 BUSINESS DAYS . 09 O u <br /> DATE T <br /> SIGNATURE OF APPLICANT Department Use Only <br /> UNIT <br /> O FILE ADDRESS <br /> a o 1.N• S�" E a If c r ❑ unit 1 <br /> 1. Street <br /> 2. Street ❑ <br /> c Urnt 2 <br /> 3. Street <br /> ar7. <br /> street Unit 3 <br /> Street .. <br /> aty <br /> street - unit <br /> Street <br /> Q <br /> . Street ❑ Unit 5 <br /> Ci <br /> 9. Street <br /> G <br /> 10. Street <br /> ENVIRONMENTAL HEALTH DEPARTMEN3 FILES <br /> 13 HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 FOOD FACILITY 13 SOLID WASTE VEHICLE <br /> U9THER CLEANUP SITE(NON-LOP) p DOG KENNEL 0 DAIRY <br /> NDERGROUND TANK(MON ITORINGIREM OVAL) a CHICKEN RANCH 0 PKG TREATMENT PLANT <br /> �" IHAZARDOUS WASTE GENERATOR ❑ CHICKENMOTELIH <br /> ❑.PUMPER TRUCKIYARDICHEM TOILETS <br /> LC3 TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ TATTOCNBODY PIERCING p OTHER(PLEASE SPECIFY) <br /> D MEDICAL WASTE FACILITY <br /> 1, List up to ten addresses in the space above. Select the-types)of files from the list above by checking <br /> pe MUST be selected. Fax to 209 464-0138 or mail to the <br /> the appropriate box(es). At least one file ty <br /> address indicated above. ointment for review will be confirmed <br /> 2. EHD will notify the applicant if any EHD files exist) An app <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 /> k <br /> 3. A file that is actively being woredon by EHD sta may not be immediately available for review. Anew <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 /> 6, *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 AP.P.Q N . <br /> T DATE. I TIME <br /> pgTt=CONlr.IRMED r PHONE FAX INITIALS <br /> REVIEWED r <br /> YES NO REVIEW DATE: <br /> EHD 48-02.006 <br /> a1812003 <br />