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DATE RECEIVED EHD LOG NUMBER <br /> ..� SAN .IOAQUIN COUNTY �., <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.orh 6 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: CeVl CQ . I�a� (�8 BUSIF)ESS/AG-`N Y: -- <br /> ADDRESS: Z(ft{ ( TZ) PAZ Df, CITYISTATE/ZIP: MQTI !4- ,, <br /> PHONE (11): tj(5 ZjS�' �{�9l/ PHONE(2): FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-'Tentadve only-must be confirmed) <br /> IP CHECK BOX TO EXPEDITE REQUEST-$122 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 ❑Unit 1 <br /> [4. <br /> [1Unit 2 <br /> ❑Unit 3 <br /> 6. <br /> 6. ❑Unit 4 <br /> 7. <br /> 8. OU R5 <br /> 119. <br /> 0. ❑Unit 6 <br /> S Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILrrYIVEHICLE <br /> p 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 ❑MOTELIHOTEL ❑PUMPER TRUCK/YARDICHEMICALTOILETS <br /> ❑TATTOOIBODY PIERCING ❑POOLISPA ❑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-6:00pm(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$122 deposit prior to review. <br /> END USE ONLY <br /> I / LS <br /> I <br /> 10-1(4- to: <br /> 0712/110 <br />