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DATE RECEIVED <br />SAN*AQLLLN COUNTYPUBLIC HEALT. ,ERVICES EHD BOG NUMBER <br />O..Y ONMENTAL HEALTH DIVISION <br />%r ':"' <br />G 7 <br />t' ., r' , +34 ST WEBER AVENUE, THIRD FLOOR C/ <br />Fill, <br />,, ,) 2002 .a STOCKTON CA 95202 <br />(209) 468-3420 <br />ErwlRu��s�EJ F!EAL(H PUBLIC RECORDS RELEASE APPLICATIONR-7 <br />— ^iLtT lr'r fel ilrG� � �,�xi� 1 <br />APPLICANT j(V "Qi� BUSINESS/AGENCY <br />ADDRESS <br />PHONE � - 4(-{ p �-� 3 a FACSIMILE <br />TENTATIVE' APPOINTMENT DATE [�)es • — t 1 JCJ <br />(Please give 7 to 10 <br />business days <br />from c <br />CHECK BOX TO EXPEDITE REQUEST - $89.00 FEE- REQ TP RJCC <br />SIGNATURE OF APPLICANT W) A,( <br />V It n <br />102- TIME - 1 2'• W <br />ate of application submittal) <br />L <br />SED IN 3 BUSINESS DAYS -1 <br />DATE <br />ENVIRONMENTAL HEALTH HEALTH DIVISION FILES <br />�NDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />�THER CLEANUP SITE (NON -LOP) <br />V,YINDERGROUND TANK (MONITORING/REMOVAL) <br />Lp' AZARDOUS WASTE GENERATOR <br />TIERED PERMITTED FACILITY <br />❑ TATTOO/BODY PEIRCING <br />❑ MEDICAL WASTE FACILITY <br />❑ HOUSING ABATEMENT <br />❑ <br />SOLID WASTE FACILITY <br />❑ FOOD FACILITY <br />❑ <br />SOLID WASTE VEHICLE <br />❑ DOG KENNEL <br />Cl <br />DAIRY <br />❑ CHICKEN RANCH <br />❑ <br />PKG TREATMENT PLANT <br />❑ MOTEL/HOTEL <br />❑ <br />PUMPER TRUCK/YARDICHEM TOILETS <br />❑ POOL/SPA <br />❑ <br />LAND USE APPLICATION SITES_ <br />❑ PUBLIC WATER SYSTEM <br />❑ <br />OTHER (PLEASE SPECIFY ABOVE) <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 $89.00 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 <br />DATE CONFIRMED <br />REVIEWED YES NO <br />TIME <br />PHONE FAX INITIALS <br />REVIEW DATE <br />