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DA*::-- RECEIVED <br />LF IU LUI; I <br />SAN JOAQUIN COUNTY <br />EN ,-IRONMENTAL HEALTH DEPARTMENT <br />304 E Webcr Ave 3rd Floor Stockton, CA 95205 ®��. <br />- 464-0138 Web: www.co.san-'oa uin.ca.tls/cl� <br />(_09) 468 3420 Fax: (209) ] q <br />APPLICANT: <br />ADDRESS: <br />PHONE: <br />PUBLIC RECORDS RELEASE APPLICATION <br />BUSINESS/AGENCY: <br />TENTATIVE' APPOINTMENT DATE: <br />FACSIMILE; <br />Time: <br />(Please allow 10 business days from date of application submittal) <br />D CHECK BOX TO EXPEDITE REQUEST - $93.00 FEE —REQUEST PROCESSED IN 3 BUSINESS DAYS // // <br />SIGNATURE OF APPLICANT DATE /l — ez 'Z�;3 <br />Department Use Only <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />(k— <br />UNIT <br />FILE ADDRESS <br />Unit 1 <br />❑ <br />Unit 2 <br />❑ <br />Cit r `L' L Q _ <br />t. <br />Streetcl <br />19 L <br />Unit 5 <br />2. <br />Street <br />DAIRY <br />ON <br />❑ <br />CHICKEN RANCH <br />0 <br />PKG TREATMENT PLANT <br />3. <br />Street <br />MOTEL/HOTEL <br />Cit <br />PUMPER TRUCK/YARD/CHEM TOILETS <br />❑ TATTOOIBODY PIERCING <br />l <br />Gt <br />a. <br />51rcc1 <br />❑ MEDICAL WASTE FACILITY <br />0 <br />OTHER (PLEASE SPECIFY) <br />V <br />COY <br />S <br />Street <br />r <br />CO <br />6. <br />Slrert <br />r <br />7. <br />Street <br />Cit <br />a. <br />Street <br />COY <br />9. <br />Street <br />Gt <br />to <br />sired <br />of <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />(k— <br />❑ UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />UNIT <br />❑ <br />Unit 1 <br />❑ <br />Unit 2 <br />❑ <br />Unit 3 <br />❑ <br />Unit 4 <br />❑ <br />Unit 5 <br />❑ UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />0 <br />HOUSING ABATEMENT <br />0 <br />SOLID WASTE FACILITY <br />❑ OTHER CLEANUP SITE (NON -LOP) <br />0 <br />FOOD FACILITY <br />0 <br />SOLID WASTE VEHICLE <br />❑ UNDERGROUND TANK (MON ITORINGIREMOVAL) <br />0 <br />DOG KENNEL <br />0 <br />DAIRY <br />❑ HAZARDOUS WASTE GENERATOR <br />❑ <br />CHICKEN RANCH <br />0 <br />PKG TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY <br />0 <br />MOTEL/HOTEL <br />0 <br />PUMPER TRUCK/YARD/CHEM TOILETS <br />❑ TATTOOIBODY PIERCING <br />0 <br />POOL/SPA <br />0 <br />LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY <br />0 <br />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 />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 />Y. 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. COPN <br />CONFIRMED APPOINTMENT DATE <br />DATE CONFIRMED <br />REVIEWED YES <br />8/&2003 <br />NO <br />PHONE <br />TIME <br />FAX INITIALS <br />REVIEW DATE <br />