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SAN V ®AQ `- I OHO 4. N g A. <br />CnV �vv at,.wu <br />-.. RONMENTAL HEALTH DEPA.R i 1T NT <br />304 E Weber Ave 3' Floor Stockton, CA 95205 __7 <br />MAR 0 5 468-3420 Fax: (209) 464-0138 Web: www-co-san-joaquin.ca.us/ehd <br />NVIRo,"Witivl HEALTH pUBL1C RECORDS RELEASE APPLICATION <br />APPLICANT` itlkA BUSINESS/AGENCY: <br />ADDRESS:��� <br />PHONE: _Q�k 53� C�y <br />FACSIMILE: <br />TENTATIVE" APPOINTMENT DATE: <br />rime• <br />(Please allow 10 business days from date of application submittal) " ��ww•.,, <br />E.. <br />® CHECK BOX TO EXPEDITE REQUEST- $93.00 FEE —REQUEST PROCESSED IN 3 BUSINESS DAYS !!-MA � <br />SIGNATURE OF APPLICANT <br />DATE <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (Lop) <br />\OTHER CLEANUP SITE (NON -LOP) <br />UNDERGROUND TANK (MONITORING/REMOVAL) <br />�I HAZARDOUS WASTE GENERATOR <br />❑ TIERED PERMITTED FACILITY <br />❑ TATTOO/BODY PIERCING <br />❑ MEDICAL WASTE FACILITY <br />1. <br />2. <br />3. <br />4. <br />5. <br />6. <br />Department Use only <br />UNIT <br />❑ Unit 1 <br />❑ Unit 2 /0 <br />e0007-\� <br />Unit 3 <br />❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br />❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br />❑ DOG KENNEL ❑ DAIRY <br />-0 <br />❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br />❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARD/CHEM TOILETS <br />❑ POOL/SPA ❑ LAND USE APPLICATION SITES <br />❑ OTHER (PLEASE SPECIFY) <br />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 (209) 464-0138 or mail to the <br />address indicated above. <br />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 />A file that is actively being worked on by END staff may not be immediately available for review. A new <br />application may be submitted when the file Is available. <br />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 <br />*TENTATIVE appointment dates must be confirmed with EHD staff. .00 deposit prior to review. <br />Application's received after 3:00 pm will be processed the next business day. <br />,;MED APP®INTMENTDATE =:.: <br />TIME <br />DATE CCONFIRM�D. .. <br />EViEiNED YES NO <br />INITLALS <br />REVIEW DATE <br />