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BATE RECEIVED EHD LOG NUMBER <br />SAN JOAQUIN COUNTY <br />- ENVIRONMENTAL HEALTH DEPARTMENT <br />4 20 i 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br />209) 468-3420 Fax: (209)464-0138 Web: www.cb.san joaquiri.ca.us/blll'd <br />VI:F 0,' l;""T HEAL.Th <br />iC ' PUBLIC RECORDS RELEASE A`PPPLICA•1 yam. � <br />APPLICANT: n4�D M1 &1 o= B <br />BUUS <br />`IN <br />,ESS/AGENCY: ��Ynl1A1 ) P ISIEV �t a"J <br />ADDRESS:32 O (�;DuGil -Sr 0(c>S_c7 <br />PHONE:%( 02'i.)" 3 *20S_ FACSIMILE: 5_9D D <br />TENTATIVE* APPOINTMENT DATE: c� 30. ZoS Time:AM <br />(Please allow 10 business days from date of application submittal) <br />CHECK BOX TO EXPEDITE REQ ST - 3 FE -REQUEST OCESSED IN 3 BUSIN ^f ��- <br />[_, � j <br />SIGNATURE OF APPLICANT DATE i7 <br />Department Use Only <br />UNIT <br />❑ Unit 1 <br />nit 2 <br />ni <br />Unit 4 <br />❑ Unit 5 <br />(k <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />E?" -UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />[B' OTHER CLEANUP SITE (NON -LOP) <br />❑ HOUSING ABATEMENT <br />❑ FOOD FACILITY <br />❑ SOLID WASTE FACILITY <br />❑ SOLID WASTE VEHICLE <br />FILTsADDRE,$ <br />131UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ DOG KENNEL <br />❑ DAIRY <br />LYiAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />I <br />As Ah <br />WfIERED PERMITTED FACILITY <br />❑ MOTEL/HOTEL <br />❑ PUMPER TRUCK/YARD/CHEM TOILETS <br />❑ TATTOO/BODY PIERCING <br />❑ POOL/SPA <br />❑ LAND USE APPLICATION SITES <br />"EDICAL WASTE FACILITY <br />❑ OTHER (PLEASE SPECIFY) <br />M���E <br />y. <br />. <br />i <br />mow• rw■ = r�-ri <br />101HI �AlU�lMt-�IIR-1I <br />ulujIAIIr0149InIil�9i <br />I <br />UNIT <br />❑ Unit 1 <br />nit 2 <br />ni <br />Unit 4 <br />❑ Unit 5 <br />(k <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />E?" -UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />[B' OTHER CLEANUP SITE (NON -LOP) <br />❑ HOUSING ABATEMENT <br />❑ FOOD FACILITY <br />❑ SOLID WASTE FACILITY <br />❑ SOLID WASTE VEHICLE <br />AP <br />131UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ DOG KENNEL <br />❑ DAIRY <br />LYiAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ PKG TREATMENT PLANT <br />As Ah <br />WfIERED PERMITTED FACILITY <br />❑ MOTEL/HOTEL <br />❑ PUMPER TRUCK/YARD/CHEM TOILETS <br />❑ TATTOO/BODY PIERCING <br />❑ POOL/SPA <br />❑ LAND USE APPLICATION SITES <br />"EDICAL WASTE FACILITY <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 />EHD 4842-008 <br />8l&2007 <br />