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Bio xe t2itxD r.nt�el <br /> DATE <br /> nm[avED -- -- SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> JUN - 304 East Weber Avenue, 3r1 Floor, Stockton, CA 95202-2708 1007%9 <br /> 2005Telephone:(209)468-3420 Fax:(209)464.0138 Web: www.sjgov.org/ebd <br /> EN ER"T/S"4 HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> JICES <br /> APPLICANT: 1Q.�Xlp__ \AmY�,LnF4 BUSINESSIAGENCY: _jr NSR <br /> ADDRESS: 10t41 OA3ackLuj '2A _ �_ SocKC1(Y�PI/t1UICA. 9EI�R-1 <br /> PHONE(1): -_QI ��� tdN Q PHONE(2): 9K.9 Afa2 —11= FACSIMILE: 41to t3(naL 8ICSO <br /> TENTATIVE"APPOINTMENT DATE: Time: rap <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be co _ _ <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED I .-- <br /> SIGNATURE OF APPLICANT DATE <br /> UNIT DISTRIBUTION ❑ UNt7 ❑ I Un 3 Una 4 ❑ Unit 5 Unit 6 ❑ Other(electroniciliststmapsI I n[,� <br /> FILE A RESS EHD USE ONLY aVyj/ <br /> Streets Street -� City <br /> r2. <br /> Jam- W� � eco 1P -S_. <br /> 9. - <br /> 10. 1 _. <br /> Specific Date Range of Information Requested: From - ] to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> Old UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 HOUSING ABATEMENT 9 SOLID WASTE FACILITYNEHICLE <br /> 15 OTHER CLEANUP SITE(NON-LOP) 0 FDOO FACILITY 1%WASTE TIRE <br /> UNDERGROUND TANK(MONITORMCJREMOVAL) 11Doc KENNEL ❑ DAIRY <br /> 0 HAZARDOUS WASTE GENERATOR Cl CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> $L TIERED PERMITTED FACILITY 0 MOiEUHOTEL 0 PUMPER TRUCKIYARDICHEM TOLETS <br /> 0 TATTOO/BODY PIERCING 0 POOLISPA M LAND USE APPLICATION SITES <br /> ❑MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW - MONDAY-FRIDAY 0:00 AM-5:00Pa - 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 /> EHD"8 2-006 - <br /> 11116 <br /> TCTRL P.0] <br />