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/29/2010/MON 03:47 PM COS - Public Worcs FAX Na, 209-937-8277 P. 002 <br /> 11/29/2010 11:36 209138 ENVIRONMENTAL IW PAGE 02/02 <br /> DATE R� IV E EHD LOG NUMBER <br /> pc SAN d0A4U1NCOUNTY �� ' ' <br /> �1G ENVIRONMENTAL.HEALTH DEPARTMENT <br /> 15 <br /> 600 East Main St, Stockton, CA 96202.3029 <br /> NOV 2 Telephond: (209)468-3420 Fax: (209)464.0138 Wabt,www-sjgov.org/ehd <br /> MENTALIIEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPIE <br /> 1 I <br /> LICANT, Ci tt 0 S�OU�✓ pN. RUSINESSIAGENCY: <br /> ADDRESS: Y dE ' VDY CrrY(STATEIZIP: grtvelLro/✓i 0--t Z <br /> PHONE(1): 7S - 3 _ PHONE(2): FACSIMILE: go /- 37-807 27 <br /> TENTATIVE"APPOINTMENT DATE: Time: <br /> (Olga%®allow 10 business days from date of application subnllttel-•Tentative only-must be enn tined) <br /> [❑CHECK BOX TO CXPEDr-F REQUEST-$122 FEE(CASH OR CHECK ONLY)•REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURL"OF APPLICANT DATE <br /> Electronic Iniarmatian: Q List❑Map—Dascrlption: <br /> FILE ADDRESS EHU USE ONLY <br /> Street Street a GNy ❑Unit1 <br /> do ,?ft AM <br /> 2 h unit <br /> 4, 13 wo till <br /> d. (9 ES�/UO <br /> T. )-ja Un i 3 Am . <br /> $ ❑Unit$ <br /> 9. <br /> 10 nit C <br /> Specific 0810 RangA of UfOnntllfog Requested: Ftvm t0 <br /> ENIVIRDNMENTAL HEALTH DEPARTMENT FILES <br /> ®UNDERGROUND TANK(U81')CLSANVP SITE(LOP) HOUSING ABATEMENT ❑8OLIDWASTE FACRNTIVOMrI,E �L 3 <br /> [aOYHERCLEANUP SITE(Nam-LOP) ®FOUPFACILITY ❑WASTETIRE <br /> UNDERGROUND TANK(MQNITDRINaIRENGYAL)p( ❑DDG KENNEL DAIRY <br /> ®.HAZARDOUS WASTE GENERATOR,( ❑CHICKEN RANCH WASTEWATER TREATMENT PLANT <br /> I9TIERED PERMITTED FACII-nY� ` ❑MoTeumarEL ❑PumPERTRUCKIYARDICHEMICAL TOILETS <br /> TAtta010OOYPIEKt"G [IP001JSPA ©LAND USE APPLICATION SITES <br /> W MEDICAL WASTE FACILITY ❑OTHER(PLEASESPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY•FRIDAY'B:OO AM- :QOPM(EXGLUOING HGLIDAYS} <br /> 1. L'% u to ten addresses In the space above. Select the typo(s)of flies from the 110 ubove by checking the appropriate <br /> bex(oe), At least one file typo MUST be selected. Fex to(20914�.9.91�@ qr mail to the address Indicated above Address <br /> ranges will not be accepted-for additional assistance with file addresses,contact the EHD. Appliontionn rocalvcd otter <br /> 3:Oo pm will be proaaaoad tho next business day. <br /> 2. The CHD will notify the applicant if any EHD files SAM. An appointment for review will be confirmed approximately ten(10) <br /> days after fec0lpt of application. The files will be held for a maximum of five business days for review. Appointments <br /> should be scheduled accordingly, <br /> 3. Afile that Is octivply being worked on by EHD staff may not be Immediately available for review, A new application maybe <br /> submitted when the file Is AvaNnbla, <br /> 4. Any file not r4tumed in the same condlNan as released will he reorganized by EHD staff at the axponse of the applicant, <br /> Future file reviews bythe same applicant may require a$122 deposit prior to review. <br /> 4flD n$EONIY <br /> EH04Wa <br />