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91 <br />DATE RECEIVED <br />EHD LOG NUMBER <br />SAN JO' IN COUNTYPUBLIC HEALTH ZFaVICES <br />IRONMENTAL HEALTH DIVISI <br />04 EAST WEBER AVENUE, THIRD FLOOR <br />APR n ;j 2003 STOCKTON CA 95202 <br />(209) 468-3420 <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT BUSINESS/AGENCY L-000 'fP. C_.V <br />ADDRESS_ 91� <br />PHONE ZC,-`) • 3 b, , 143( FACSIMILE ZC.!P1 • 'anof. . 3 Z_ <br />TENTATIVE* APPOINTMENT DATE TIME <br />(Please give 7 to 10 business days from date of application submittal) <br />® CHECK BOX TO EXPEDITE REQUEST - $89E - REQUEST P O ESSED IN 3 BUSINESS DAYS 14 nif 40r <br />r, <br />/ I <br />SIGNATURE OF APPLICANT DATE <br />FILE ADDRESS THIS SIDE EHD STAFF USE ONLY <br />PROGRAM ELEMENTS SEARCH <br />1�(LrI <br />c(c �� l %1(�� �c �3T4c c`c+ v�C,rn�1•� f� C'(SZ zo <br />PHRI 11 D <br />I <br />15 KOJ <br />ENVIRONMENTAL HEALTH DIVISION FILES <br />A UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />HOUSING ABATEMENT <br />❑ SOLID WASTE FACILITY <br />tR OTHER CLEANUP SITE (NON -LOP) <br />❑ <br />FOOD FACILITY <br />❑ SOLID WASTE VEHICLE <br />M UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ <br />DOG KENNEL <br />❑ DAIRY <br />1, HAZARDOUS WASTE GENERATOR <br />❑ <br />CHICKEN RANCH <br />❑ PKG TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY <br />❑ <br />MOTELIHOTEL <br />❑ PUMPER TRUCK/YARD/CHEM TOILETS <br />❑ TATTOO/BODY PEIRCING <br />❑ <br />POOL/SPA <br />A LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY <br />❑ <br />Z ❑ 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 (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 $89.00 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 />EHD 48.01.006 <br />I .G.A! <br />