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DATE RECEIVED <br /> - EHD LOG NUMBER <br /> ( SAN_JOAQUIN COUNTY <br /> n C[ iJ 1J 4_�D ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br /> J U:L 2 6 kim),4.68-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> P R IT/SEER�RVICTS - <br /> APPLICANT:^✓,4 y RAN CN O-Z' BUSINESSIAGENCY: <br /> ADDRESS: 22 S 67• #14 MM ZIA tJ <br /> PHONE:' o26 <br /> $ 2 I� FACSIMILE: �>7 5 2- 3 D <br /> 4 1 - Lf I� cc-err <br /> TENTATIVE*APPOINTME' DATE: Time, <br /> (Please allow 10 business days from date of application submittal) <br /> I <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE—REQUEST PROCESSED 3 BUSINESS DAYS `] <br /> SIGNATURE OF APPLICANT , <br /> DATE C ' Q <br /> Department Use Only <br /> v <br /> FILE ADDRESS UNIT <br /> 7- street a o 1,N• S T N u f G T ❑ Unit 1 <br /> 2. street f <br /> l tor <br /> 3. Scree! f" G ❑ Unit 2 <br /> 4. Street <br /> a <br /> s. street C' Unit 3 rr ,1 <br /> 6. Street a' 1d <br /> 7. Street Unit 4 <br /> 9. Street <br /> 9. Street C' E] Unit 5 <br /> l <br /> G <br /> S0. Sweet <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> V4ZNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> yfl THER CLEANUP SITE(NON LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL d DAIRY <br /> FHI <br /> © CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> AZAfZDOUS WASTE GENERAT0 MOTEUHOTEL Cl PUMPER TRUCKIYARDICHEM TOILETS <br /> ERED OR PERMITTED FACILITY ❑ POOLISPA d LAND USE APPLICATION SITES <br /> ❑ TATTOoIBODY PIERCING ❑ OTHER(PLEASE SPECIFY) <br /> 13 MEDICAL WASTE FACILITY <br /> 1. List up to ten addresses in the space above. Select the type(s) of files from the list above hy checking , <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(2091464-0138 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 /> ays for review. Appointments should be scheduled <br /> will be held for a maximum of five business d <br /> accordingly, <br /> 3. A file that is actively being worked on by EHD staff 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 /> 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 /> TIM <br /> CONFIRMED APPOINTMENT DATE.. <br /> ONE FAX': INITIALS <br /> 1)ATE CONFIRMED. = - <br /> REVIEWED YES NO REVIEW DATE <br /> E91348-02-006 - <br /> 8182003 <br />