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x/18/2006 10:59 FAX Z 002/002 <br /> DATE RECEiVVEE(D� (� �`/] [� 0 SAN EHO LOC NUMBER <br /> I�E C E� �/ E`�;NVIRONMENTAL HEALTH DEPARTMENT <br /> JAN 1 n, - East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br /> TeQeplioee: (209)468-3420 Fax: (209)464-0138 Web:www_sjgov_org/ehd <br /> ENVIRONMENT HEALTH 1113 <br /> P❑MiT/SERVITUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: O S BUSINESSIAGENCY: <br /> ADDRESS: 2 Z- CITY____ST ice/ STATE,, <br /> PHONE(1W_X1/ q 11 ( y PHONE(2): FACSIMILE: ` <br /> TENTATIVE"APPOINTMENT DATE: -/ I (o _ Time: i Z_ <br /> (Please allow 10 business days from date of application submittal-*Tentadve only-must be confirmed) <br /> © CtIECK BOX TO EXPEDITE REQUE T 4474M FEE H OR CHECK ONLY)-REQUEST PROCESSED IN 3 DUSINE.iS DAYS <br /> SIGNATURE OF APPLICANT DATE IElectronic <br /> Information List d Map-Description <br /> FILE ADDRESS EHD USE ONLY' <br /> stmt Street Name City <br /> 1• Pl <br /> 2, � ) Iq <br /> El Unit 1 <br /> 3' P KID C Unit 2 <br /> 4. 't 1 (� . <br /> S. Unit 3 <br /> 6. <br /> 7. Unit 4 <br /> s. <br /> g, ❑ Unit 5 <br /> Z.unit 6 <br /> SpeGflc Date Range of Information Requested:From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> hf UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 HOUSWa ABATEmPAT _W SOLID WASTE FACILITYNENICLE <br /> t5OTHER CLEANUP SITE(NON-LOP) 0 FOOD FACxj y CO WASTE TIRE <br /> UNDERGROUND TANK(MONITOMNWREMOVAL) 0 DOG KENNEL T7 DAIRY <br /> Z HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH ASTEWATER TREATMENT PLANT <br /> ❑ TIERED PERMM CD FACKM ❑MOTELIHOTEL 0 PUMPER TRUCK/YARDICHF-MICAL To1LETs <br /> 11 TAT OWBODY PIERCING 0 POOUSPALAND USE AFF LICATrom Sn"u <br /> 13MEDICAL WASTE FACILITY 0 OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERRLA RECORDS ARE AVAILAALe FOR REVIEW-MONDAY-FRIDAY a:00 A AZ:00PM - EXCLUDING HOUDAYS. <br /> 1, List up to ten addresses in the space above, Select the type(s)of files from the list above by checking the <br /> appropriate box(es). At least one file type MUST be selected. Fax to (20914"l 38 or mail to the zlddress <br /> indicated above. Address ranges will not be accepted—for additional assistance with file addresses,contact <br /> the EHD.Applications received after$: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 <br /> approximately ten(10)days after receipt of application. The flies will be held for a maximum of five business <br /> days for review. Appointments 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 <br /> application may be 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 expfinse of the <br /> applicant. Future file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> END 4;Oi <br /> 10/312006 <br />