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UNI C KC�.CIYCU SAN JOAQUIN COUNTY <br /> ENVII.`NMENTAL I1EALTII DEPARTMEl . <br /> �_.., 304 E Weber Ave 3`d Floor Stockton,CA 95205 <br /> MAY <br /> 1 2 2004(209) 468-3420 Fax: (209) 464-0138 Web:www.co.sanjoaquin.ca.us/ehd <br /> EAL1H PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: I\kGIv\ BUSINESSIAGENCY: <br /> ADDRESS: <br /> PHONE:��( 5 (�Ui— �( h FACSIMILE: <br /> TENTATIVE'APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Depadnent Use Only <br /> FILE ADDRESS UNIT <br /> 1. shed 5 <a C ❑ Unit 1 <br /> 2. shed Og <br /> 3. shed Cky ❑ Unit 2 (J� <br /> !. Sheetcity � �/]� <br /> s. she« citf Unit 3 <br /> 6. street Cky <br /> 7. shed oty Unit 4 <br /> a. shed <br /> 9. sued Cky Unit 5 <br /> 1o. shed <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-.OP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> P�UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> E3 TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ TATTOO(BODY PIERCING ❑ POOUSPA ❑ LAND USE APPLICATM SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <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$93.00 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 ARA OINTMENT ATE - TIME - <br /> f' <br /> DATCONFIRMED ':. . PHONE': FAX' iNiTIAI:'S <br /> ZEVIEVNED _ 'YES NO REVIEW DATE <br /> EHO 4"2-006 <br /> SM7003 <br />