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DATE RECEIVED EHD LOG NUMBER <br />SAN JOAQUIN. COUNTY41 <br />niL�`s I! °; !`lj ENVI NMENTAL HEALTH DEPARTMiE.NT <br />304 E Weber Ave 3rd Floor Stockton, CA 95205 <br />OCT - �2Q%68-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd <br />ENVIROIVIEW flE.ALiFiPIMLIC RECORDS RELEASE APPLICATION <br />1., <br />i Ll IMI , <br />APPLICANT: BUSINESS/AGENCY: <br />ADDRESS:9-Q >c_4S�LI(tl �2L9 A <br />PHONE: <br />FACSIMILE: <br />i" <br />TENTATIVE* APPOINTMENT DATE: <br />(Please allow 10 business days from date of <br />® CHECK BOX TO EXPEDITE REQUEST - $93.00 FEE — REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT / DATED <br />Department Use Only <br />UNIT <br />❑ Unit 1 Ll r <br />❑ Unit 2 <br />V <br />tt 4 IMM <br />❑ Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />FILE DRESS <br />HOUSING ABATEMENT <br />t. <br />Street <br />j <br />/ <br />Cit <br />2. <br />Street <br />SOLID WASTE VEHICLE <br />ity <br />3. <br />Street <br />S <br />f <br />City <br />4. <br />Street <br />CHICKEN RANCH <br />Cit <br />5. <br />6. <br />Street <br />Street <br />r rz)(j W ' <br />cit <br />Cit <br />7. <br />Street <br />❑ TATTOO/BODY PIERCING <br />Cit <br />POOL/SPA <br />❑ <br />8. <br />Street <br />❑ <br />Cit <br />9. <br />Street <br />city OCIV <br />10. <br />Street <br />Q <br />Department Use Only <br />UNIT <br />❑ Unit 1 Ll r <br />❑ Unit 2 <br />V <br />tt 4 IMM <br />❑ Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />HOUSING ABATEMENT <br />❑ <br />SOLID WASTE FACILITY <br />❑ OTHER CLEANUP SITE (NON -LOP) <br />❑ <br />FOOD FACILITY <br />❑ <br />SOLID WASTE VEHICLE <br />UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ <br />DOG KENNEL <br />❑ <br />DAIRY <br />'HAZARDOUS WASTE GENERATOR <br />❑ <br />CHICKEN RANCH <br />❑ <br />PKG TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY <br />❑ <br />MOTELIHOTEL <br />❑ <br />PUMPER TRUCK/YARDICHEM TOILETS <br />❑ TATTOO/BODY PIERCING <br />❑ <br />POOL/SPA <br />❑ <br />LAND USE APPLICATION SITES <br />MEDICAL WASTE FACILITY <br />❑ <br />OTHER (PLEASE SPECIFY) <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 />EHD48-02-006 <br />8/8/2003 <br />