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DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, Web: 3029 J Ora/ <br /> Telephone: (209)468-3420 Fax: (209)464-013838 Web:wwwsjgov. d <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: Ky1a n02Y BUSINESSIAGENCY: �q[ tlti s. i•�'E}Vr <br /> ADDRESS: ZS2 GLAylN SI City/S <br /> ltate/Zip ��t,��IER I ct) k 211 q r� <br /> PHONE(,): 3. g5• �3�5 PHONE(2): �'ZD.� .z-�L1 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•5105 FEE(CASH OR CHECK ONLY).REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT" Ir.l{•-�^'t. DATE 1z�t ?`}P� <br /> Electronic Information: ❑List❑ Map- Description: <br /> FILE ADDRESS EHD USE ONLY <br /> pStreet# k Street Name City <br /> I„[If•� 1• Ur �?J �• _ E] Unit, <br /> Yv1 � + 10 <br /> 2• Unit 2 <br /> 4• Unit 3 <br /> 5. <br /> 6. nit 4 \ <br /> 7. \6 ❑ UNtS <br /> 9. <br /> 10. ❑ Unit 6 <br /> Specific Date Range of Information Requested:From 2000 to '00� <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> M'UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYNEHICLE <br /> IJOTHER CLEANUP SITE(NON-LOP) 13 FOOD FACILITY ❑WASTE TIRE <br /> El UNDERGROUND TANK(MONRORINGIREMOVAL)vv` O DOG KENNEL Cl DAIRY <br /> M HAZARDOUS WASTE GENERATOR(I ` ❑CHICKEN RANCH WASTEWATER TREATMENT PLANT <br /> O TIERED PERMITTED FACILITY ❑MOTELIHOTELL�jPUMPERTRUCK/YARD/CHEMTOILETS <br /> El TATTOO/BODY PIERCING ❑POOL/SPA ES LAND USE APPLICATION SITES <br /> MMEDICAL WASTE FACILITY 9( ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW•MONDAY-FRIDAY 8:00 AM•S:OOPM .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 mall 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 /> k41120 -Z00 ' 'e <br /> q4846 <br /> tow. 2- <br /> 4lOe PUBLIC RECORDS RELEASE APP FORM <br /> �- � <br />