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ATE RE DIVED ' ¢!lt14g0 iJVMeE>Z <br /> SIOAQUIN COUNTYPUBLIC HEALTERVIC <br /> ENVIRONMENTAL HEALTH DIV(WN <br /> 304 EAST WEBER AVENUE,THIRD FLOOR <br /> STOCKTON CA 95202 <br /> (209)468-3420 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> Or /•� � Ir <br /> APPLICANT 1.t 1C�`�'.t-�S o k, BUSINESSIA13ENCY 1'+y a/ ����� f <br /> ADDRESS <br /> PHONEr201)137,-2 31'd FACSIMILE <br /> TENTATIVE*APPOINTMENT DATE ASAP AiY V� TIME 1A <br /> (Please give27 to D business d s fr licallon submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$8WO 0x�U TPR N 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT CNS 6­9�� DATE <br /> y <br /> FILE ADDRESS THIS SIDE END STAFF USED <br /> PROGRAM ELEMENTS SEJAR <br /> �/2 S' �.r� f=1 9.i..I� c1Cf--• 'tS 2 u ti .. <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> O UNDERGROUND TANK(UST)CLEANUP SITE(LOP) O HOUSING ABATEMENT M SOLID WASTE FACILITY <br /> ❑ OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY O SOLID WASTE VEHICr•LE \ <br /> `' <br /> ❑ UNDERGROUND TANK(MONITOR(NGIREMOVAL) O DOG KENNEL 13DAIRY Off( <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH 8 PKG TREATMENT PI.MT - <br /> O TIERED PERMITTED FACILITY 0 MOTEUHOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOOIBODY PEIRCING O POOLISPA 9 LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY 0 PUBLIC WATER SYSTEM O OTHER(PLEASE SPOCIFY ABOVE) <br /> 1. List up to ten addresses in-'the space above. Select the type(s)of flies from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(2001464-01al or mall to the <br /> addrg_ss indicated above. <br /> 2. EHO will notify the applicant If any EHD flies exist. An appointment for review will be V' onfirmed <br /> approximately five business days but no later than ten(10)days after receipt of application. The flies <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. Ane <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$89.00 depo's)t prior to review. <br /> S. `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 /> Z/Z 86ed `•99:9G ?O-LI.-Am `•Z6£LL£66OZ !sNuOM#3Il9fld#N01)i301S#d0#A1I3 :A9 TuaS <br />