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_0 '?010! 100 03: 43 PM COS - Public Works FP,:i Ido, <br /> 11/29/2010 11:36 209, 138 ENVIRONMENTAL H, H PAGE 02/02 <br /> DATE R C �® EHD LOG NUMBER <br /> �( SANJtJaQU1N COUNTY <br /> R ENVIRONMENTAL HEALTH DEPARTMENT <br /> 9 ZQ�Q 600 East Main St, Stockton, CA 96202.3029 <br /> N� Telephone: (209)468-3420 Fax: (209)464.0136 Web:www_sjgov.orglehd <br /> MENTA�HEpLTH PUBLIC RECORDS RELEASE APPLICATION <br /> 1 <br /> APPS CANT: t 0 , S10 J_(22 <br /> BV$INESSiAGENCY: <br /> ADDRESS: v2e� Y dE r T` 00)" CITYISTATEIZIP. 9ro^/ CA <br /> PHONE(1): C, 3 PHONE(2), FACSIMILE: ZZ 2- 29 7—Y2 Z7 <br /> TENTATIVE"APPOINTM NT DATE: Time: <br /> (Please allow 10 business days from ate of application submittal-'Tentative only-must be can nncd) <br /> CHECK DO\TO kxpEDITE rcoVEST-$122 FEE(CASH OR CHECK ONLY)-REQU98T PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLIGANT DATE <br /> Electronic Information; [j List 1]Map—Description, <br /> FILE ATIDRESS EHD USE ONLY <br /> 51r�M M Street N e city ❑Unit 1 <br /> i 'y 'fn f 'gmmP 47o Kin <br /> 2. �n R Unit 2 <br /> 3 <br /> �. 0 G S,,AJO W <br /> nit o <br /> '- _ ' ' c l tel i �✓� 0 <br /> 8. ❑unus <br /> 9. <br /> 10, nit s <br /> Specific Date Rango of Iniormativn Requestad: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES ] <br /> ®UNDERGROUND TANK(UST)CLEANUP SITE(LOP) HOUSING ABATEMENT ❑SOLID WASTE FAGiLTTYNCHiCLE <br /> EaOTHER CLMUF SiTE(NON-LOP) HFOOD FACILITY ❑WASTE TIRE <br /> Z-UNDERGROUND TANK(hM0NiTORINI3IRFVQVAL)0( ❑DDG KENNEL DAiRY <br /> [;§-HAZARDOUS WASTE GEHERATORp\ CI CHICKEN RANCH WASTEWATER TREATMENT PLANT <br /> 9TIERED PERMrrm FACILiTY(n ©MOTELiHOTEL ❑PUMPLRTRUCKNARDICHEMicAL TOiLETB <br /> T'AT1001800YPiMCING ❑PWlJ8PA ❑LAND USE APPLiCATi0NSITES <br /> W MEDICAL WASTE FACtUTY Q OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT FtECOROS Alit!AvAILABLE FOR R£v1Ew: MONDAY-FRIDAY OI.GD AM.S,'QOPM(EXCLUDING HOLIDAYS) <br /> 1. L(At u to ten addresses In the space above. Select the types)of files from the lint above by checking the appropriate <br /> hax(ac). At least one file"MUST be selected_ Fwcto_(xt�bl r mall to the address Indicated alb Address <br /> Address <br /> rangns will not be accepted-for additional assistance with file addresses,contact the EHD. Appliontlanx rocolvod gftor <br /> 3:00 pm will be processed the noxt business day. <br /> 2. The T:HU will notify the applicant If any EHD files exist, An appointment for review will bo confirmed approximately ten(10) <br /> days after receipt of application. The Vies will be held for a maximum of five business days for review. Appointments <br /> should be scheduled accordingly, <br /> 3. A file that is aActivoly being worked on by EHD staff may not be IM Modiately available for review. A now application may be <br /> submitted when the flle Is evall&blo, <br /> 4. Any file not raturmed in the same condltlan as rsleasad will bo rebrganired by EHO staff at the expense of the applicant. <br /> Future file reviews by the some applioant may raquira a$122 deposit prior to review. <br /> lim WE OALY <br /> Ewa 4149 <br />