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DA RECEIVED EHD LOG NUMBER <br /> ,r a SAN JOAQUIN COUNTY r <br /> f N I <br /> ERONMENTAL HEALTH DEPARTM NT <br /> MAYv 213 1868 East Hazelton Avenue, Stockton, CA 95205-6232 t[ J <br /> Telephone. (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> Et iti?€?PSt4FNTALHEALH <br /> Pry('Ai'/aFCitrlGEti PUB/LIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESS/AGENCY:_ G111ely- <br /> ADDRESS: do CITY/STATEIZIP: a S Z <br /> PHONE(1): I(o -1 PHONE(2): FACSIMILE:_ JB�/-/IOJ <br /> TE VE'APPOINTMENT DATE: Time: <br /> (Please allow 10 business daysa of application submittal-'Tentative only-must be confirmed) <br /> ❑CHECK BOX TO EXPEDITE REQUE -$ E ASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUS S DAYS <br /> SIGNATURE OF APPLICANT DATE 3 <br /> Electronic Information: ❑ List❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> street a Street Name city _-.- ❑Unit 1 <br /> �./ 2. ❑Unit 2 <br /> 3. <br /> 4. Unita <br /> 5. <br /> 6, nit4 V�(a) <br /> 7. <br /> 8. ❑Unit 5 <br /> 9. <br /> 10. ❑Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> NDERGROUNDTANK(UST)CLEANUP SITE(LOP) ❑MEDICALWASTE FACILITY ❑SOLID WASTE FACILItYNEiICLE ¢ <br /> [AZARDOUS <br /> THER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> NDERGROUND TANK(MONITORINGIREMOVAL)� El FOOD FACILITY El DAIRY <br /> BOVEGROUNDTANK ❑CHICKEN RANCHI DOG KENNEL ❑WASTEWATERTREATMENT NLANT <br /> WASTEIHAZARDOUS MATERIALS` ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USEAPPLICATION SITES <br /> ❑TATTOOIBODY PIERCING ❑COMPLAINTIRESPONSE 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. "'BOXED AREA-EHD USE ONLY*** <br /> ❑ Records provided by Staff-PPR Complete. staff Name: <br /> EHD 48-0e 914M2 <br />