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El CHECK BOX TO EXPEDITE REQU EE-RE ROCE 0 IN 3 BUSINESS DAYS <br />DATE SIGNATURE OF APPLICANT <br />UNIT <br />ID Unit 1 <br />Unit 2 <br />Unit 3 <br />Unit 5 <br />06/15/2004 09:44 <br /> 2099316 7 A3 <br /> WATERLOO SHELL <br /> PAGE 01 <br />END LOG NUMBER <br />DATE RECEIVED <br />JUN 1 5 2 <br />ENVIRONMENT HEALTH <br />HEKIVil I <br />APPLICANT: <br />ADDRESS: c13 /5- 6 . U)/417 <br />PHONE: <br />:114.i • <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E Weber Ave 3 rd Floor Stockton, CA 95205 <br />) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd <br />PUBLIC RECORDS RELEASE APPLICATION <br />BUS1NE5S/AGENCY: <br />n (4- ,STock ,21(), z-os— <br />FACSIMILE: <br />It 53 <br />TENTATIVE* APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application Submittal) <br />i - <br />FILE ADDRESS i <br />s. ti,3 is ti_A114.1.in /GC .6 Cdy <br />_ 1 <br />Sra.:14 City <br /> <br />Citty <br /> $trae <br />Stnyyt. City <br /> <br />Sa-sieit City <br />5 <br />&Mei C. B. <br />57W <br />City <br />- 7. <br />8 Sb'e,t <br />City <br />S0N4 <br />City <br />8 <br />10 $tr.i.t <br />City <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />t UNDERGROUND TANK (UST) CLEANUP arrE (LOP) <br />OTHER CLEANUP SITE (NON-LOP) <br />UNDERGROUND TANK (MONITORING/REMOVAL) <br />HAZARDOUS WASTE GENERATOR <br />0 TIERED PERMITTED FACIUTY <br />TM-MO/BODY PIERCING <br />MEDICAL WASTE FACILITY <br />HOUSING ABATEMENT <br />FOOD FACILITY <br />In DOG KENNEL <br />In CHICKEN RANCH <br />MOTEUHOTEL <br />POOL/SPA <br />OTHER (PLEASE SPECIFY) <br />SOLID WASTE FACILITY <br />ri SOLID WASTE VEHICLE <br />in DAIRY <br />pKG TREATMENT PLANT <br />PUMPER TRUCKNARDICHEM TOILETS <br />LAND USE APPUCATION SITES <br /> <br />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 mall to the <br />address indicated above. <br />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. A tile 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 />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 soma applicant may require a $93.00 deposit prior to review. <br />*TENTATIVE appointment dates must be confirmed with EHD staff. <br />Applications received after 3:00 pm will be processed the next business day. <br />CONFIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX <br /> INITIALS <br />REVIEWED YES NO REVIEW DATE <br />ENO al-02-006 <br />UWAEO