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DATE RECEIVED SAN 1I11M EHD LOG NUMBER <br /> RECH V ED EN*ONMENTAL HEALTH DEPARTMINT <br /> JUN 0 ZUjI(1 600 East Main St. Stockton, CA 95202-2708 <br /> elephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/e <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> DGRAhIT/CERI/lf`F <br /> APPLICANT: BUSINESS/AGENCY: `Q-H&-yWL0(q <br /> ADDRESS: T I I CITYISTATE/ZIP: <br /> PHONE (1): L/7L/,- 2 ,66)0 PHONE (2): 2 — FACSIMILE: Y, <br /> TENTATIVE*APPOINTMENT DATE: Time: r <br /> (Please allow 10 business days from date of application submittal-•Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$115.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT_ " v oitZ2 `bl ) . DATE blL l O <br /> Electronic Information: ❑ List ❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name city <br /> r 1 351 �GiV`f ShGJVI % S f Unit1 <br /> 2. oq Au 6l/Z Sh t� 5 ❑ unN2 <br /> 3. <br /> 4. <br /> it 3 16 <br /> 5. <br /> 6. <br /> Unit 4 <br /> 7. <br /> 8. <br /> _ ❑ Units <br /> 9. <br /> 10. <br /> ��'� '� ww '� "� ❑ Unit 6 <br /> Specific Date Range of Information Requested: From G1 0"4U-) , to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES I /Qq C <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) <br /> EI ABATEMENT ❑SOLID WASTE FACILITYNEHICLE I / <br /> OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL)(J.- ❑DOG KENNEL ❑DAIRY <br /> HAZARDOUS WASTE GENERATOR a ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> TATTOOIBODY PIERCING ❑POOLISPA. <br /> F1 MEDICAL WASTE FACILITY El LAND USE APPLICATION SITES <br /> ❑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 pe(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$115.00 deposit prior to review. <br /> EHD USE ONLY <br /> ***If you need further assistance lease contact Diane Martinez direct) @ (209)468-3425. Thank You*** <br /> ©r7D5y8Z i 5 ' r -- <br /> S61 1 <br /> aun ensa <br />