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DATE ftEG�iveu <br /> MD ��ril /�2 D SAN J��IVIRONMENTAL HEALTH DIVISION <br /> ICES <br /> ���- I�,l SII jC .� <br /> 304 EAST WEBER AVENUE,THIRD FLOOR <br /> STOCKTON CA 95242 ✓_ -~ <br /> DEC 1 1 2000 (209)468-3420FNVsx <br /> IRONMEN1" HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> uI <br /> tjto <br /> APPLICCANit <br /> - 54BU5INESSIAGENCY <br /> ADDRESS L10,95— Al. /0SQ Q �MLAU�JQ1)n�AP� I`P5O�2 <br /> o PHtiNED FACSIMILE <br /> �C- <br /> TENTATIVE`APPOINTMENT DATE 11-11 4o TIME <br /> (Please glvs T to 1 D business days from data of application submittal) <br /> Q CHECK BOX TO EXPEDITE REQUEST-$78.00 Fr;E—RE UEST PR CESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE P ' � <br /> FILE APPRESS <br /> r oft f� r a-9s3 <br /> I <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> Nd UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT D SOLID WASTE FACILITY <br /> Q OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> O UNDCRGROUND TANK(MONITORINGIRtMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR U CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEQHOTEL to PUMPER TRUCKIYARDICHEM TOILETS <br /> C3 TATTOOIBODY PEIRCING ❑ POOUSPA O LANs USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY D PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1. 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 file type MUST be selected. Fax to(20 464-0'138 or mail to the <br /> address indicated above. <br /> An appointment for review will be confirmed <br /> 2. EHD will notify the applicant if any EHD files exist. <br /> approximately five business days but no later than ten(10)days after rentspt of should sched TheUled files <br /> will be held for a maximum of five business days for review. App <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 /> 4. Any file not returned in the same condltlon as released will be reorganized by END staff at the expense <br /> of the applicant. Future file reviews by the same applicant may require a$78.00 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 /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EH DD 14 07105MO <br />