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ECOVED r <br />DATE <br />WIT <br />2013 SAN JOAQUIN COUNTY <br />PARTMENT <br />ENVIRONMENTAL HEALTH 1868 East <br />ENVIRONMENTAL <br />Avenue, Stockton,DE <br />CA 95205-6232 <br />PERMIT(SERVICESTelephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />APPLICANT: <br />ADDRESS: <br />PUBLIC RECORDS RELEASE APPLICATION <br />EHD LOG NUMBER <br />BT)SINESS/AGENCY: <br />C4TYI—STATEIZIP: <br />PHON /(p- P1­19NE(2): FACSIMILE:L4?0!j) �'� % I I U <br />EN ATIVE•APPOINTMENT DATE: Time: <br />(Please allow 10 businessd a of application submittal -•Tentative only- must be confirmed) <br />CHECK BOX TO EXPEDITE RE ST 5 (CASH OR CHECK ONLY) -REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE '? <br />Electronic information: E] List Map- Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />❑ Unit 1 <br />Street# Street Name <br />City <br />1. <br />q �4i sfxee <br />P <br />�C-0 �.f ❑Unit 2 <br />3.+A`+�10 <br />1� <br />PnXT> c0r_p <br />Unit 3 <br />4. <br />Init4 <br />6. <br />3. <br />Z <br />No eo* <br />El Unit 5 <br />8. <br />9. <br />❑ Units <br />10. <br />1 rgyle1 L ieC <br />Specific Date Range of Information Requested: From / to ) <br />,,��,� ENVIRONMENTAL HEALTH DEPARTMENT FILES �I\e6 <br />&'UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE FACIUTYIVEHICLE 3 <br />�❑0 ER CLEANUP SITE(NON•LOP) ❑ HOUSING ABATEMENT ❑WASTETIRE <br />ERGROUND TANK (MONITORINGIREMOVAL) ❑ FOOD FACILITY ❑ DAIRY <br />OVEGROUND TANK ❑ CHICKEN RANCHI DOG KENNEL ❑ WASTEWATER TREATMENT PLANT <br />T1fZARDOUS WASTEIHAZARDOUS MATERIALS ❑ MOTELIHOTEL ❑ PUMPERTRUCKIYARDICHEMICAL TOILETS <br />IERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br />❑ TATTOOIBODY PIERCING ❑ COMPLAINTIRESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <br />WELLAND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 5:00 AM-5:OOPM (EXCLUDING HOLIDAYS) <br />1. List un 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_ "`BOXED AREA - EHD USE ONLY`*" <br />Staff Name: <br />