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DATE RECEIVED <br /> I�j SAN JOp,QUI( COUNTY EHO LOG NUMNtR <br /> G° EC RE--D Pr4VIRONMENTAL HEALTH DE.PA:1 I'MENT <br /> 304 E Weber. Ave 3`d Floor Siockton, CA 95205 14*070 <br /> ucL 2 1 20��09)468-3420 Fax: (209)464-0138 Web: www.co,san-joaquin.ca.us/ehd <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELuASE APPLICATION <br /> C Alo; I Aje(^Se,,j �SSdcIp�2S <br /> APPLICANT: "s�•yt�.c.q �, �IrJ$Ce`> BUSINESSfIAG�EINCY: q /l <br /> ADDRESS: ✓5Tr/1a� <br /> PHONE: d–� 7J -7 _3 /7 O FACSI�/M�IILF: 0,0 <br /> TENTATIVE'APPOINTMENT DAT Ne•r ��, -A_T, I ODA,(— <br /> (Please allow 10 business days from data of application submittal) <br /> Q CHECK SOXTO EXPEDITE RE U ST"$93.0 BE–REQUEST PROCESSED IN 3 BUSINESS DAYS ] <br /> DAC� / <br /> SIGNATURE OF APPLICANT Department Use only <br /> MO <br /> PILE ADDRESS <br /> t, Slrcet V j 1! l,�.r t at 51 LI C dr' �/ � ��CI2. StreetQWx ef` � �,. see 4v c 52 s.> dwN .c <br /> 5" 4 WI {,s v `. CAIa. S 1 oC <br /> S -col <br /> S ut S �Unit4 <br /> r. Street eC <br /> a, street So L,wu�1,•.+Si C <br /> ci, ❑ Unit 5 <br /> 9. stree <br /> _. ..-01 <br /> t0. 31ree1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> C3 HOUSING ABATEMENT E3 SOLID WASTE FACILITY <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 FOOD FACILITY 0 SOLID WASTE VEHICLE <br /> ® OTHER CLEANUP SITE(NON-LOP) O DAIRY <br /> la UNDERGROUND TANK(MONITORING(REMOVAL) O DOG KENNEL 13 pKG TREATMENT PI-ANT <br /> DS HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL PA E3 LAND USE APPLICATION SITES <br /> 13OOTHER <br /> M TATTO01BODY PIERCING ❑ ( <br /> ❑ MEDICAL WASTE FACILITY OTHER(PLEASE SPECIFY) <br /> P <br /> 1. List up to ten addresses in the space above. thtype(s) <br /> ysele(s) f Fax tofiles o th46st above1138 mall checking <br /> the appropriate box(es). At least one file type MUSTe <br /> o the <br /> address indicated above. <br /> 2• EHD will notify the applicant(f any EHD files exist. An appointment for review will be confirmed <br /> The <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 /> g. 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 /> Eflp 6&az-0OG <br /> dOf2007 <br />