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AGE.STl7CKTQN ~..PAGE'" - 01/fl <br /> EHD LOG NUM6ER <br /> SAN JOAQUJX COUNTY i <br /> l <br /> :SEP ENVIRONMENTAL HEALTH DEPARTMTNT <br /> $ 2004. 304 E Weber Ave 3rd Floor Stockton,CA 95205 <br /> ENVIRQf�P,�li J�x(209)468-3420 Fax: (209)464-0138 Web: www.co.san joaquin.ca.us/ehd <br /> PERMIVSER+VICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESSlAOENCY: JI - <br /> ADDRESS: ,�I <br /> PHONE: 2QL — FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: L Time: <br /> (Pleaea allow 10 bus;inasa days from date of application submltt Q <br /> CHECK BOX TO 1 JCPEDfFE EiEQUr T•$93.00 FEE—REGtUEST CESSE IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE Q <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> x suet a ❑ Unit 1 <br /> a simm CR <br /> y <br /> 4. smrs ❑ Unit 2 1 r <br /> i <br /> 5. Sheet CRY <br /> s Unit 3 f <br /> ci <br /> 7. 6heatCRY n <br /> 8. Street <br /> - 9 S et � <br /> stmt <br /> El "Unit 6 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES W MS0 0 <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT 0 SOLID WASTE FACRU H <br /> OTHER CLEANUP SITE(NON.LOP) 0 FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINCMEMOVAL) ❑ DOC KENNEL 0 DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH 0 PXG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELlHOTEL 0 PUMPER TRUCKIYARD(CHEM TOILETS <br /> C1 TATTOOlBODY PIERCING O POOLISPA L D LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECI ' <br /> 7. 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 fele type MUST be selected. Fax to 1209)464-0738 Or mail to the <br /> address Indl Ove. <br /> 2. EHD will npttfy 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. I <br /> 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new <br /> application maybe submitted when the File is available. <br /> d. Any file not returned in the same condition as released wilt be reorganized by EHD staff at the expense 1 <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 /> fi. Applications received after 3:00 pm will be processed the next business day. <br /> COfWkRM1rD'PPOINTMENi'PATE— <br /> hV[E• i <br /> bATt COFIfiFalflliEl <br /> PRON'- 'FA7C itllFTl41:�.._: <br /> Y1=S TSO` <br /> EHD 4e-0T4)0e <br /> are/2001 <br /> t <br /> 'I <br /> } <br /> ' 'r <br />