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_ _DAi'_E RE�EIVI:O . <br />SAN JOAQU1rN COUNTY- LZ}cu wc; NUM a,ur <br />EN -,'TRON1Y EN'irAL HEALTH DEPARTMENT <br />PAR7('IY.(JENT <br />304 E Weber Ave 3r0 Floor Stockton, CA 95205 <br />NOV 14 2003 (2009) 468-3420 Fax, (209) 464-0138 Web: wavwn.san-j0aqu11ua.dehd <br />VORUNMEPvT HEATH PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: 0 UNL BUSINESS/AGENCY: <br />ADDRESS: ' r <br />PHONE: sd��j FACSIMILE: <br />TENTATIVE` APPOINTMENT DATE: Time. <br />(Please allow 10 business days from date of application Submittal) <br />l <br />CWCHECK BOX TO EXPEDITE REQUEST - $93.00 FEE — RERUES PROCESSED IN 3 BUSINESS DAYS 25 <br />SIGNATURE OF APPLICANT DATE <br />V <br />V <br />41) Y <br />Department Use Only <br />Unit 1 <br />1 G('�� <br />e <br />Unit 4 <br />Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES � U 66 U L60 <br />K'THER <br />NDERGROUND TANK (UST) CLEANUP SfrE (LOP) k]" HOUSING ABATEMENT CI SOLID WASTE FACILITY �C CLEANUP SITE (NON -LOP) f"FOOD FACILITY O SOLID WASTE VEHICLE <br />ERGROUND TANK (MONITORING/REMOVAL) O DOG KENNEL 0 DAIRY <br />IAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH 0 PK TREATMENT PLANT <br />TIERED PERMITTED FACILITY 0 MOTEUHOTEL OPjFUMPER TRUCKtYARD/CHEM TOILETS <br />CI TATTOO/BODY PIERCING O POOL/SPA PLAND USE APPLICATION SITES <br />MEDICAL WASTE FACILITY O OTHER (PLEASE SPECIFY) <br />1. List up to ten addresses in the space above. Select the type(s) of files from the list aboye by checking <br />the appropriate box(es). At least one file type MUST be selected. Fax to -(2091 4464-0138 or mail to the <br />address indicated above. <br />2. EHD will notlfy 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 fide 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 />CONFLRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX INITIALS <br />REVIEWED .. YES NO REVIEW DATE <br />EMD d8-02-406 <br />WV2993 <br />FILE ADDRESS <br />1. <br />SVedt <br />w <br />1. <br />Sumrt <br />city <br />3. <br />street <br />cityf <br />4. <br />Street <br />` <br />5. <br />Street <br />d <br />c,t <br />e. <br />Svices <br />� GI <br />Gtt <br />8. <br />SUiet <br />9. <br />-SUCCI <br />n j (;It <br />-K/ <br />to. <br />Sired <br />15 <br />— - GI <br />41) Y <br />Department Use Only <br />Unit 1 <br />1 G('�� <br />e <br />Unit 4 <br />Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES � U 66 U L60 <br />K'THER <br />NDERGROUND TANK (UST) CLEANUP SfrE (LOP) k]" HOUSING ABATEMENT CI SOLID WASTE FACILITY �C CLEANUP SITE (NON -LOP) f"FOOD FACILITY O SOLID WASTE VEHICLE <br />ERGROUND TANK (MONITORING/REMOVAL) O DOG KENNEL 0 DAIRY <br />IAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH 0 PK TREATMENT PLANT <br />TIERED PERMITTED FACILITY 0 MOTEUHOTEL OPjFUMPER TRUCKtYARD/CHEM TOILETS <br />CI TATTOO/BODY PIERCING O POOL/SPA PLAND USE APPLICATION SITES <br />MEDICAL WASTE FACILITY O OTHER (PLEASE SPECIFY) <br />1. List up to ten addresses in the space above. Select the type(s) of files from the list aboye by checking <br />the appropriate box(es). At least one file type MUST be selected. Fax to -(2091 4464-0138 or mail to the <br />address indicated above. <br />2. EHD will notlfy 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 fide 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 />CONFLRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX INITIALS <br />REVIEWED .. YES NO REVIEW DATE <br />EMD d8-02-406 <br />WV2993 <br />