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MAY, 18. 2004- 2:08PM ,-""9NTGGMERY WATSON N0. 923EH°LP• 11I"'8ER . <br /> Cou�vTY <br /> DATE RECf=1VED A---) ��Jo�QvI�T - <br /> r'- [e 1�1 D )ENVMONWNTAL HEALTuDUATWNT <br /> 304 E Weber Ave Yd Floor Stockton,CA 95205 <br /> MAY 18 209)468-•3420 Fax- (209)464-01M Web:v;""- .sa6}oaquin.ca.uslehd <br /> HEALTH LTS ,IC ECORDS RELEASE APpLICA►TION <br /> BUSINESSlAGENCY: <br /> APPLICAN r: v �E <br /> ADDRESS', } <br /> PHONE, – � <br /> 'f —Time• <br /> TENTATIVE"APPoINWENT DATE: <br /> (Plessa allow 10 bttsines6 days from date of applieation submi0l) <br /> I� <br /> Ct[FCK BOX TO EXPEDITE REgUEST-393 00 FEE–REQUEST pIiOCESSEo 1N$BUSINESS DAYS <br /> Sl(,NATIJRE OF APPLICANT 42rtFn nt Usg OMY <br /> SIE UNIT <br /> FILE ADDRESS <br /> .�� fifi�Gc!✓ i CR Unit'1 <br /> z s cit f# Unit 2 <br /> s. s <br /> 000 u <br /> a• s � ��. c <br /> s. easel o,., d Unit <br /> z. s,,aat t-700 o <br /> s, svee� <br /> 9. 5 at <br /> o, s�rea� <br /> ENVIRONMENTAL C)EPAR 11WIENT FILI S <br /> if <br /> 13 HOUSING ABATEMENT ❑ SOUR WASTE FACILITY <br /> UNDERGROUND YANK(UST)CLEANUP SITE(LOP) [3 FOOD FACILITY 17 SOLID WAS VEHICLE <br /> In oTHER CLEANUP SITE(NON-LOP) ❑ DOG KENNEL ❑' DAIRY <br /> > tINDEiiGROUND TANK(MONITORINGIREMOVAL) ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> 0 HAZARDOUS WASTE GENERATOR G MOlELIHOTEL if ❑ PUMPERTRUCKIYARD1ChiEM TOILETS <br /> ❑ TIERED PERMITTED FACILITY CI pooUSPA it ❑ LAND USE APPLICAn SITES <br /> ❑ TATTOO[BODY PIERCING d OTHER(p LEASE SPECIFY) <br /> ❑ MEDICAL WASTE FACILr(Y h' <br /> S(S)s of fides from the list above by checking <br /> 1. List up to ten addresses in the space above. Select the typ ( ) <br /> thea ra date box(es). At(east one file type MUST be selected. Fax to ;?U9 46d-0138 or mail to the <br /> pp 'P <br /> address indicated above. appointment for review will be confirmed <br /> 2. EHO will notify the applicant if any EHDut n files exist. to app receiptapplication. The files <br /> approximately five business days but no later than ten(10)days Appointments shoulbe scheduled <br /> will be held fora maximum of five business days for review. App <br /> accordingly. available far review. A nem <br /> g, A file that is actively being worked on by EHO Staff may n t be immediately <br /> application maybe submitted when the file is availableby 15RD staat the- <br /> 4. Any file not returned in the same condition as releas;d�nt may req iireza$93.00 deposit prior to evictµ <br /> Iates Of the applicant Future file reviews by the Sante app <br /> 5• <br /> 6. processed lness day*TENT reived after pm will be the next busi <br /> Appllcatons ec <br /> ',1 .n• f, I <br /> ,�, .e s «}ti ,lin '� �{'w • ' '.,; •' t.• ^ar �, Y ,,• �• <br /> �C+❑ p ll�T1 ,lr IAT ;.-� ,, ,�.• ,.,:. 'q'y1` • <br /> ,l' ' ', ^S' w ,.'` '` y"S1%�rl•f �.S.�., L...-. I <br /> nV i, , • <br /> RE�fIr=tAt YES <br /> = t <br /> END AM-G24W <br /> ' araneos <br />