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11-14-2ktiV Lt ibFf'I Ftp <br /> uaie xLGiwL`0 <br /> j [W ✓ ��\ F v +•" -� Ettu itK3 HUh1Li2lt <br /> SAN JOAQUIN COUNTYPUBLIC HEALTH S :RVICES <br /> ENVIRONMENTAL HEALTH DIVISION 2+1 <br /> 304 EAST WESER AVENUE,THIRD FLOOR <br /> STOCKTON CA 93202 <br /> (209)468••3420 <br /> POBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT LO'Qr LIUSINEWAGENCY W l k ►'L�' 'T .j, o cr <br /> AODRESs � C G r r7 s <br /> PHONE — FACSIMILE f�/f9� � /oC— f 0 �_S <br /> TENTATIVE"APPpiNTMENT DATE TIME <br /> {Please gtvt 7 to 10 duslnews days from date of application submittal) <br /> CHECK BOX TO EXReDITE REQUEST-$87.00 FEE—REQ T PROCESSED IN 3 13USENESS DAYS <br /> SIGNATURE OF APPLICANT GATE <br /> FILF ADDRESS THIS SIDE EHD STAFF USE ONLY <br /> PROGRAM ELEMENTS STARCH <br /> o� c <br /> O D S -r r q <br /> v CT <br /> M ee r 4P eye <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> NDEROROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING A13ATEMENT ❑ SOLID WASTE FACILTrY <br /> OTHER CLEANUP SITE(NON-LDP) ❑ FOOD FACILITY Q SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORiNWREMOVAL) ❑ DOG KENNEL ❑ RAIRY <br /> HAZARDOUS WASTE.GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> El TIERED PERMITTED FACILITY 0 MOTEl1HOTEL ❑ PUMPER TRUcriYARDlCHEM TOILETS <br /> CI TATTo01BODY PEiRCING m POOUSPA II LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACII I T Y O PUSLIC WATER SYSTEM I3 OTHER(PLEASE SPECIFY ABOVE) <br /> 1. List up to ten addrtlsses In the space above. Select the type(s) of files from the list above by chocking <br /> the appropriate boxlesj. At least one file type MUST be selected. Fax to [209)44§4& ,aQr 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 /> accoGbingly. <br /> 3. A flle that is actively baing worked on by EHD staff my not be Immediately available for review. Anew <br /> application may be submitted when the file is available. <br /> 4. Any Bile not returned In the same condition as released will be reorganized by EHD staff at the expense <br /> of the applicant. Fatum flle reviews by the same applicant may require a $87.00 deposit prior to review. <br /> 6. 'TENTATIVE appointment dates trust be conflrmed with FHD staff. <br /> 6. Applications received after 3:00 pm will be processed the next 4usiness day. <br /> CONFIRMED APPOINTMENT BATE TIME <br /> DATE CONFLRM[D PHONF- FAA INITIALS <br /> REVIEWED YES NQ RF-VIEW DATE <br /> • n ao t� o raa <br /> TOTRL P.01 <br />