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EHD LOG NUMBER <br /> DATE RECEIVED SAN JOAQUIN COUNTY <br /> RIE CENED ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E Weber Ave 3'Floor Stockton, CA 95205 <br /> i U L 2 468-3420 Fax: (209)464-0138 Web:www.co.san-joaquin.ca.us/ehd <br /> ENVIRONMENT REALTH PUBLIC RECORDS RELEASE APPLICATION <br /> PFRMIMERVICES <br /> APPLICANT: �/1 y /[A N CN O D BUSINESS/AGENCY: <br /> ADDRESS: q z2 S LC• Hf}MM�R LAS srot,� T® <br /> PHONE: S 2 46 FACSIMILE: :2fl 9 5 2 3 0 Lt S <br /> 41" (c-ett <br /> TENTATIVE*APPOINT- DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE—REQUEST PROCESSED 3 BUSINESS DAYS �] <br /> SIGNATURE OF APPLICANT DATE 6 0 <br /> Department Use Only <br /> G FILE ADDRESS UNIT <br /> 1. Street <br /> 2 O 1.N• ST e G G t ❑ Unit 1 <br /> 2. Street <br /> 3. Street /_Gty' ❑ Unit 2 <br /> 4. Street <br /> city <br /> 5. street ci Unit 3 /1 <br /> 6. Street 7. c' 000, - 1 4�1 <br /> Street CiN Unit 4 <br /> e. Street C <br /> ity <br /> 9. street city Unit 5 <br /> 10. Street Ci <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ,UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> Zy�THER CLEANUP SITE(NON-LOP) 13 FOOD FACILITY 13 SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> CHICKEN RANCH PKG TREATMENT PLANT <br /> �FHAZARDOUS WASTE GENERATOR 1313MOTEUHOTEL El13PUMPER TRUCK/YARD/CHEM TOILETS <br /> IERED PERMITTED FACILITY ❑ POOL/SPA ❑ LAND USE APPLICATION SITES <br /> ❑ T ERICA WAS PIERCING ❑ OTHER(PLEASE SPECIFY) <br /> ❑ MEDICAL WASTE FACILITY <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(209)464-0138 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 /> 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 /> 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 /> CONFIRMED APPOINTMENT DATE TIME - <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHO 48-02-006 <br /> 8/8x1003 <br />