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EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT `7 <br /> NOV 2008 600 East Main Street, Stockton, CA 95202-3029 <br /> Ei'JVIR0N'; cfJ i ritrlT�Irphone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> F'Ehtttii/'S; hVI ur,ES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: %' BUSINESS/AGENCY: e4-lis <br /> ADDRESS: �l(�— � - �S --` .0 City/State/Zip <br /> PHONE(1 PHONE(2): 2 FACSIMILE:: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of a6plicatioti submittal-"Tentative only-must be confirmed) <br /> El CHECK BOX TO EXPEDITE REQU W9$105 FEE(C CHECK,ONLY)-REQUEST PROCESSED IN 3 BUSINESS D YS <br /> SIGNATURE OF APPLICANT � .1 � DATE 11611 <br /> Electronic Information: ❑ List ❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City <br /> Unit 1 <br /> OILYI t Unit 2 <br /> 4 <br /> 4. <br /> g �Q 5p Unit 3 \� <br /> i!C`�C ti <br /> 5. Cy f"� i< s a /A <br /> 6 �/ Unit 4 <br /> 7t! viow' -0772 (i /Joc(b, �f <br /> 7. Y2 !f° IL <br /> Z ❑ Unit 5 <br /> 8. 1j pis, Na �/h <br /> 9. 3 <br /> ❑ Unit 6 <br /> 10. <br /> Specific Date Range of Information Requested:Froin to <br /> ENVIRONMENTAL HEALTH EPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY/VEHICLE <br /> 1 OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑WASTE TIRE ��/I l ✓�' rj� <br /> K UNDERGROUND TANK(MONITORING/REMOVAL ❑ DOG KENNEL ❑ DAIRY <br /> KHAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT 1 <br /> ❑TIERED PERMITTED FACILITY ❑MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑TATTOO/BODY PIERCING ❑POOL/SPA ❑ LAND USE APPLICATION SITES <br /> ❑MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <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$105 deposit prior to review. <br /> EHD USE ONLY <br /> — r C 019 c v <br /> EHD 48-06 8104/08 PUBLIC RECORDS RELEASE APP FORM <br />