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DATE RECEIVED EHD LOG NUMBER <br /> RSAN JOAQUIN ECEIVED ENDO MENTAL HEALTH oDEPARTAPT <br /> V 2 600 East Main St. Stockton, CA 95202-3029 <br /> ] 2 ZO <br /> Telephone. (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: (A(n(�� ( � �� BUSINESS/AGENCY: <br /> ADDRESS: c�� CITYISTATE/ZIP: <br /> PHONE (1): ,�v b 6 PHONE (2): FACSIMILE: <br /> 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-$125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 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 1 <br /> 1. C� ( iahT z s 0 <br /> 2. <br /> ❑ Unit 2 <br /> 3. <br /> 4. 1�� <br /> Unit 3 <br /> 5. <br /> 6. <br /> Unit 4 <br /> 7. <br /> 8. <br /> ❑ Unit 5 <br /> 9. <br /> 10. <br /> ❑ Unit 6 <br /> Specific Date Range of Information Requested: From to �/ <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES /r(J <br /> NDERGROUND TANK(UST)CLEANUP SITE(LOP) E]HOUSING ABATEMENT E]SOLID WASTE FACILITYNEHICLE <br /> THER CLEANUP SITE(NON-LOP) [jFOOD FACILITY ❑WASTE TIRE U/71 3 <br /> NDERGROUND TANK(MONITORINGIREMOVAL)O—ii ❑DOG KENNEL El DAIRY <br /> 0f ❑ I 1 G IZ <br /> AZARDOUS WASTE GENERATOR ❑CHICKEN RANCH WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY C� ❑MOTELIHOTEL E]PUMPER TRUCKNARDICHEMICAL TOILETS <br /> f❑ TTOo/BODY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY Pr'6 RECORDS ❑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(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$125 deposit prior to review. <br /> E11D USE ONLY <br /> EHD 4806 811111 <br />