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s <br />DATE RECEIVED <br />SAN JOAQUIN COUNTY <br />EHD I.OG NUMBER <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 23131 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/chd <br />A PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: AFTIAUR _DF ICK(c BUSINESS/AGENCY: AjV nQ& CTCO 461'(anwv <br />ADDRESS: <br />3l Shaw ROCL6 <br />Cv4un <br />PHONE (1): PHONE (2): <br />TENTATIVE* APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application submittal -*Tentative only - must be confirmed) <br />jq CHECK BOX TO EXPEDITE RE EST 3.00FEE ASH 0 K ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE S " ""0' ;006 <br />UNIT DISTRIBUTION <br />Cl Unit 1 ❑ Unit 2 ❑ Unit 3 13 Unit 4 ❑ Unit 5 0 Unit 6 13 Other (electronicllistslmaps) <br />FILE ADDRESS <br />EHD USE ONLY <br />Street # Street Name City <br />Y <br />lINS e� CltaT r W fo <br />2. <br />3. <br />44. <br />6. <br />7. <br />9. <br />10. <br />Specific Date Ranae of Information Reauested: From (q to f)Yf <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITYIVEHICLE <br />OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ WASTE TIRE <br />UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br />HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ WASTEWATER TREATMENT PLANT <br />TIERED PERMITTED FACILITY O MOTELIHOTEL 11PUMPER TRUCKIYARDICHEM TOILETS <br />TATTOOIBODY PIERCING 13POOLISPA ❑ 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 <br />appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address <br />indicated above. Address ranges will not be accepted —for additional assistance with file addresses, contact <br />the EHD. Applications received after 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 <br />approximately ten (10) days after receipt of application. The files 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 expense of the <br />applicant. Future file reviews by the same applicant may require a $93.00 deposit prior to review. <br />cn41 wuzuae <br />1114105 <br />4\ <br />