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uu . i L1.Lw Lu SAN JOIN COUNTYPUBLIC HEALTH SICES 1-140 I�OG NUMI3GH EI � IRONMENTAL HEALTH DIVISIOP, 304 EAST WEBER AVENUE, THIRD FLOOR STOCKTON CA 95202 (209) 468-3420 p Y . PUBLIC RECORDS RELEASE APPLICATIO f 11 E � APPLICANT Dl ADDRESS 540)( BUSINESS/AGENCY Vj PHONE <L� (p1�'- �� fJ _ FACSIMILE TENTATIVE* APPOINTMENT DATE TIME (Please give 7 to 10 business days from date of application submittal) r' CHECK BOX TO EXPEDITE REQUEST 9.00 FELE z' SIGNATURE OF APPLICANT PROCESSED IN 3 BUSINESS DAYS DATE 5-Zj a 2 - FILE FILE ADDRESS THIS SIDE EHD STAFF USE ONLY PROGRAM ELEMENTS SEARCH 14/c79 L Fn/7t--R i'lZ est S Vii' s T� ❑ UNDERGROUND TANK (UST) CLEANUP SITE (LOP) 13 HOUSING ABATEMENT WASTE FACILITY • �' /Ji`'% K C! 5 r � A-UJ�zEs � L N.rca/. -��/ ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE ❑ UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT ❑ TIERED PERMITTED FACILITY ❑ MOTEUHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS ❑ TATTOO/BODY PEIRCING ❑ POOL/SPA ❑ LAND USE APPLICATION SITES ❑ MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ OTHER (PLEASE SPECIFY ABOVE) ENVIRONMENTAL HEALTH DIVISION FILE�;/SOLID ❑ UNDERGROUND TANK (UST) CLEANUP SITE (LOP) 13 HOUSING ABATEMENT WASTE FACILITY ❑ OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE ❑ UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT ❑ TIERED PERMITTED FACILITY ❑ MOTEUHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS ❑ TATTOO/BODY PEIRCING ❑ POOL/SPA ❑ LAND USE APPLICATION SITES ❑ MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ OTHER (PLEASE SPECIFY ABOVE) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address indicated above. 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately five business days but no later than ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a $89.00 deposit prior to review. 5. *TENTATIVE appointment dates must be confirmed with EHD staff. 6. Applications received after 3:00 pm will be processed the next business day. CONFIRMED APPOINTMENT DATE TIME DATE CONFIRMED PHONE FAX INITIALS .1 REVIEWED YES NO REVIEW DATE m.nt•nnr es