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DATE RECEIVED COUNTYSAN JOAQUIN EHD LOG NUMBEE <br /> RECEIVE® ENWONMENTAL HEALTH DEPARTAT <br /> 2 2012 600 East Main St. Stockton, CA 95202-3029 <br /> Jr-,iv <br /> Telephone. (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> v <br /> ENVIRONMENTAL HEALTH <br /> PERMff/SERVICES <br /> PUBLIC <br /> - RECORDS RELEASE APPLICATION <br /> APPLICANT: 01r,(A(f P (\ 'V),(-[, BUSINESS/AGENCY: <br /> ADDRESS: 1 CITY/STATE/ZIP:31ki—c!�y <br /> PHONE (1): �?_d b PHONE (2): 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-$125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City 1 <br /> 1. — t UST Z S / <br /> 2. <br /> ❑ Unit 2 <br /> 3. <br /> In 4.6.7. <br /> 8. <br /> 9. <br /> 10. <br /> ❑ Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> INTIEDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT El SOLID WASTE FACILITYNEHICLE <br /> RED <br /> HER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE (A/9) 3 <br /> DERGROUND TANK(MONITORINGIREMOVAL)O-22 ❑DOG KENNEL ❑DAIRYZARDOUS WASTE GENERATOR O ❑CHICKEN RANCH F1WASTEWATER TREATMENT PLANT <br /> PERMITTED FACILITY G?'� ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> TTOO/BODY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY COMPLAINT RECORDS ❑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$125 deposit prior to review. <br /> EHD USE ONLY <br /> EHD G8 06 <br /> 811111 <br />