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DATE RECEIVED OAQUIN COUNTY EHD LOG NUMBER.. <br />�SAN <br />�` ENO MENT ski <br />AL HEALTH DEPART T <br />1" 600 East Main St. Stockton, CA 95202-2708 <br />Y`elephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.©rg/e <br />ENVIROMIENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT:_ I 1<�C 1<'62 )fV1 BUSINESSIAGENCY:-- <br />ADDRESS: q %'/ A X01<' rl Uc //� CITY/STATE/ZIP: <br />PHONE (1): _L12 Y— 2 00()0 PHONE (2): 'l g 2. 2 FACSIMILE: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- $111155,00 FEE (CASH OR CHECK ONLY) -REQUEST PROCESSED 1N 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE <br />Electronic Information: ❑ List ❑ Map — Description: <br />_ FILE ADDRESS EHD USE ONLY <br />Street # Street Name City , ) <br />Unit 7 <br />2. 3a�?�yy Sf7c•}r� y' r <br />3. - 1 V_O �_i�_LUf �? �- [] Unit 2 Y16 <br />5. <br />6. <br />_ - Unit 4 <br />7. <br />8. <br />--- _ ❑ Unit 5 <br />L190- <br />❑ Unit 6 <br />Specific Date Range of Information Requested: From l/j1/ to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES��}�1 <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITYNEMCLE <br />OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY <br />WASTE TIRE <br />UNDERGROUND TANK (MONITORINGIREMOVAL) ( ❑ DOG KENNEL ❑ <br />HAZARDOUS WASTE GENERATOR ❑ DAIRY <br />CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br />TIERED PERMITTED FACILITY ❑ MOTE'LIHOTELrr��11 <br />TATT001$ODY PIERCING u PUMPER TRUCKIYARDICHEMICAL TOILETS <br />❑ POOLISPA ❑ 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 (2091464-0138 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 Please contact Diane Martinez direct) @ (209)468-3425. Thank You <br />rV.3 15 <br />P"n <br />