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EHD LOG NUMBER <br /> DATE RECEIVED <br /> 1vED SAN JOAQUIN COUNTY <br /> RE E V D ENV RONMENTAL HEALTH DEPARTM <br /> r1LE UP <br /> 600 East MainSt. Stockton., CA 95202-302 q <br /> APR Q 6 201,k, :tune: (209) 468-3420 Pax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH <br /> PERP )TISER1110ES_-..•TrJBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: 14 ��� BUSINESS/AGENCY: <br /> ADDRESS: � �l CITYISTATEIZIP: q, <br /> PHONE (1): Jfa- �' 1�1� PHONE (2): FACSIMILE: ��Y _Z <br /> TENTAT/VE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-'Tentative only--must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE RE $,1,25 FEE EO CHECK ONLY)"-REQUEST PROCESSED IN 3 BU51NESS DAYS <br /> SIGNATURE OF APPLICANT DATE - <br /> Electronic Information: ❑ List Map-- Description:` <br />'I FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City Unit 1 <br /> i <br /> 2. ❑ Unit 2 <br /> 3. <br /> i <br /> 4. ❑ Unit 3 <br /> 5. <br /> 6. C ❑ Unit 4 <br /> 7. <br /> ❑ Unit 5 <br /> 9. <br /> 10. ❑ Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> I <br /> 0 ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING.-ABATEMENT ❑SOLID WASTE FACILITYIVEHICLE <br /> ❑OfHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORINGIREMQVAL) ❑DOG KFNNEL ❑DAIRY <br /> ❑HAZARDOUS WASTE GENERATOR a ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTELIHOTEL ❑PUMPER TRUCKfYARDICHEMICAL TOILETS <br /> ❑TATTOOIBODY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑COMPLAINT RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR,REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> 1. List up to ten addresses in the space above. Select the ty;pe(s) of files from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to (209)464-0138 or mail to the address indicated above. Address <br /> ranges will not be accepted -for additional assistance with file addresses, contact the EHD. Applications.received after <br /> 3:00 pm will be processed the next business day. <br /> l 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten(10). <br /> days after receipt of application. The files will be held for a maximum of five business days for review..Appointments <br /> should be scheduled accordingly. <br /> 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be <br /> 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 of the applicant. <br /> Future file reviews by the same applicant may require a'$125 deposit prior to review. <br /> ii EHD USE ONLY f r <br /> , <br /> �ih J� 0-S-12 Z2,_ <br /> EHD 46-06 6l1f11 <br />