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DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> Pyne: (209) 468-3420 Fax: (209 464-0138 Web: www.s ov.or /ehd <br /> � 19 9 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: � ���,� BUSINESS/AGENCY: <br /> ADDRESS: CITY/STATE/ZIP: :� �e�,q, <br /> PHONE (1): � � PHONE (2): FACSIMILE: <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 REQUEST-$122 FEE(6SH R CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE �p--3��-`\ <br /> Electronic Information: ❑ List ❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑ Unit 1 <br /> mac, <br /> 2. ❑ Unit 2 <br /> 3. <br /> 4. <br /> ❑ Unit 3 <br /> 5. <br /> 6. <br /> ❑ Unit 4 <br /> 7. <br /> 8. <br /> ❑ Unit 5 <br /> 9. <br /> 10. <br /> ❑ Unit 6 <br /> Specific Date Range of Information Requested: From to / <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES j ,s/ CrLij��j <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITY ERICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE IC' <br /> NDERGROUND TANK(MONITORINGIREMOVAL) ❑DOG KENNEL ❑DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH <br /> ❑WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY <br /> ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TATTOOIBODY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY OTHER(PLEASE SPECIFY) A- <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 expens he applicant. <br /> Future file reviews by the same applicant may require a$122 deposit prior to review. <br /> EHD USE ONLY <br /> ffPS 42 <br /> (� <br /> EHD 48-06 <br /> n>nnun <br />