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�v <br />DATE RECEIVED EHD LOG NUMBER <br />SAN .,IOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main St. Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.or <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: i r <br />�� _ 2Z ,(�� BUSINESS/AGENCY: <br />ADDRESS: CITY/STATE/ZIP:�l <br />PHONE (1): PHONE (2): FACSIMILE: <br />TENTATIVE* APPOINTMENT DATE: Time: <br />/ (Please allow 10 business days from date of application submittal - *Tentative only - must be confirmed) <br />CHECK BOX TO EXPEDITE REQUEST - $115 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE <br />Electronic Information: ❑ List ❑ Map — Description: <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND <br />TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />UNDERGROUND TANK (MONITORING/REMOVAL <br />❑ DOG KENNEL <br />,❑ HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />Z TIERED PERMITTED FACILITY C?(, <br />❑ MOTEL/HOTEL <br />FILE ADDRESS <br />❑ POOLISPA <br />EHD USE ONLY <br />� Unit <br />4a' ?�L1-nit 2_ <br />IUo dbl <br />nit 3 <br />1. <br />Street # <br />Street Name city <br />"i >-o <br />/ _ <br />GL > 7 >F'. <br />2. <br />3.C� <br />1 <br />C'i�l �� %C <br />/C���c �� l� —_ �r <br />4. <br />C.� ��! <br />e q-_ ,-1 <br />uv <br />/( '" <br />( t <br />5. <br />t S` 5 0 <br />V` <br />P0/�J <br />kb Will <br />�il'J <br />it 4 <br />6. <br />tl L10.6% <br />/) <br />-P7 <br />7. <br />S Gf .� <br />/U' c'1% 1'f'Sg 1 <br />❑ Unit 5 <br />❑ Unit 6 <br />8. <br />9. <br />Specific Date Range of Information Requested: From <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND <br />TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />UNDERGROUND TANK (MONITORING/REMOVAL <br />❑ DOG KENNEL <br />,❑ HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />Z TIERED PERMITTED FACILITY C?(, <br />❑ MOTEL/HOTEL <br />❑ TATTOOIBODY PIERCING <br />❑ POOLISPA <br />❑ MEDICAL WASTE FACILITY <br />❑ OTHER (PLEASE SPECIFY) <br />to <br />❑ SOLID WASTE FACILITYNEHICLE <br />❑ WASTE TIRE UA <br />❑ DAIRY n <br />❑ WASTEWATER TREATMENT PLANT tA(Z <br />❑ PUMPER TRUCK/YARD/CHEMICAL TOILETS -1-I ' IU <br />LAND USE APPLICATION SITES <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:00PM (EXCLUDING 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 $115 deposit prior to review. <br />5. If you need further assistance, please contact Diane Martinez, at (209) 468-3425. <br />1=1411 IICF 11,11 V <br />- 91l11w►.ic �^i►�7 <br />l•l�ar� Lit! �l►3iL� L�n��Jatt�u�16► 1i�1�I�!7L.�i�l/IaMIM oil <br />8/27/09 <br />