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DATE RECEIVED <br />SAN JOAQUIN COUNTY EHD LOG NUMBER <br />�.� ENVIRONMENTAL HEALTH DEPARTMENT <br />{�600 R3029 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: 0www.s www.sjgov.org/ehd <br />19 org/ehd <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: -.?C -t( - <br />BUSINESS/AGENCY: _-6r ,i5 cr_�>er aq c,Z.1 <br />ADDRESS: �,�, 3 / CITY/STATE/ZIP: Q r ,•q , CA '"Al <br />PHONE (1): 9 ,LS- �' .$-qPHONE (2); 9-" ' I - c} FACSIMILE: 44 (3 - 931114 <br />TENTAT/VE`APPOINTMENT DATE: 7 <br />(Please allow 10 business daysfrom date of application submittal -'Tentative only- must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST - $125 FEE (CAS R CHE ONLY) - REQUEST PROCESSED IN 3 BU (NESS DAYS <br />SIGNATURE OF APPLICANT <br />— DATE <br />Electronic Information: ❑ List ❑ Map - Dr scription: <br />FILE ADDRESS <br />- _ _ EHD USE ONLY <br />Street # � -- - <br />Street Name <br />City <br />— ---- ---- -- Unll) <br />2 tc <br />1 3. �Unit 2 <br />4. ***PLEASE RESPOND AS SOON AS POSSIBLE. <br />5. I NEED TO NOTIFY APPLICANT DURING - — ------ - -- J;aiiiillnit 3 <br />6 WEEK OF 5/14/12 IF EHD HAS FILES FO%,, <br />7. LISTED ADDRESSES OR NOT. <br />------- -�--. nit 4 a <br />8. <br />l IQ <br />-7� <br />�. _ - _ �.__-- ---- El Unit 5 " <br />10. <br />IW-rZ <br />Specific Date Range of Information Requested: From ! ❑Unit 6 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES to <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT— <br />OTHER CLEANUP SITE (NON -LOP) ❑ SOLID WASTE FACILITY/VEHICLE <br />TANK (MONITORING)REMOVAL) ❑ FOOD FACILITY ❑ WASTE TIRE <br />❑ DOG KENNEL <br />9–UNDERGROUND <br />HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑ DAIRY <br />❑ TIERED PERMITTED FACILITY[:1WASTEWATER TREATMENT PLANT <br />ElTATTOOIBODY PIERCING ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARDICHEMICAL TOILETS <br />❑ ❑ POOUSPA ❑ LAND USE APPLICATION SfTES MEDICAL WASTE FACILITY❑COMPLAINT RECORDS <br />HER (PLEASE SPECIFY <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 A❑M 5TOOPM (EXCLUDI G)HOLIDAYS) <br />1. List up to ten addresses in the space above. Select the type(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 />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 />IL 11 <br />HD 48- <br />y <br />��..�/12 <br />