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07/24/2009 10:22 7149602462 MILLER BROOKS ENS/ PAGE 01 <br /> F EHD LOG NUMBER <br /> r''r\` SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> !f., H ! 1009 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/e <br /> -50ow. soo� <br /> EW F'0'tJ ILE rti iL/,LFH <br /> PUBLIC RECORDS RELEASE APPLiCATION <br /> . �ytil�lP�t' ra� snv�ra�w� <br /> APPLICANT: BUSINESSIAGENCY: _ �J <br /> ADDRESS: 4 Y*`C/� ,� �� (� Cltyl-Stta`telZip �0� La /_0_ <br /> PHONE(1): PHONE(2): �y� ( �✓y� FACSIMILE: �I�'rl — b �L1�_ <br /> TENTATIVE"APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from data of application submittal-"Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$1D EE(CA H OR CHECK ONLY)-REQUEST PROCESSED iN 3 BUSINES DAYS <br /> SIGNATURE OF APPLICANT DATE a LI <br /> Electronic Information: ❑ List❑ Map Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# S�Tx.� <br /> Street Name City `?�� i] Unit 1 <br /> 1. t <br /> 2. �(►i <br /> 3. <br /> nit 3 <br /> 4. <br /> 6. U <br /> 7. ; <br /> ❑ Unit 5 <br /> 8. <br /> 9. (� unit 6 p �� <br /> Specific Date Range of Information Requested:From to <br /> UNDERGROUND ENVIRONMENTAL HEALTH DEPARTMENT FILES TANK(UST)CLEANUPSITE(LOP)✓ E] HOUSING ABATEMENT ©SOLID WASTE FACILITYNEHICLE <br /> THER CLEANUP SITE(NON-LOP) 12 FOOD FACILITY ❑WASTE TIRE <br /> NDERGROUND TANK(MONITDRINGIREMOVAL) 0 DOG KENNEL ❑DAIRY <br /> D HAZARDOUS WASTE GENERATOR O CHICKEN RANCH t7 WASTEWATER TREATMENT PLANT <br /> *TIERED PERMITTED FACILITY 13 MOTEUHOTEL 17 PUMPER TRUOKIYAROICHEM TOILETS <br /> O TATTOOBODY PIERCING ❑POOLiSPA 0 LAND UsZ APPLIC TION SITES 1 <br /> MEDICAL WASTE FACILITY OTHER(PLEASE SPECIFY) �t1U�(M ,,i Cti a%_�c's <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE POR REVIEW - MONDAY-FRIDAY 8:00 AM-6:00PM - 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 well be processed the next business day. <br /> 2. The EHD will notify the applicant If any EHD files exist. An appointment for rfeview 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 retumed 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 /> Fri)✓, 1` (-O DO <br /> EHD 48-06 M41013 PUBLIC RECORDS RELEASE APP FORM <br />