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3AIN JOAQUIN UOUNTY <br /> ENV' 7NMENTAL HEALTH DEPARTN4T <br /> 6*East Main Street, Stockton, CA 95202 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sigov.org/(- d !� <br /> PUBLIC RECORDS RELEASE APPLICATION l q <br /> APPLICANT: (`e-N�- E ,S, LL- tje BUSINESSIAGENCY: <br /> ADDRESS: _7y 7 F • 05 C s e!^_1 � 4 o—P— C� <br /> PHONE(1):�r AI It — I?974- PHONE(2): O`OQ — tet-:5Q - a- ( FACSIMILE: <br /> TENTATIVE`APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of icationn submittal-`Tentative only-must be confirmed) <br /> CHECK BOX TO EXPEDITE R�$ o <br /> (CASH OR EC E EST PROCESSED IN 3 BUSINESS DAYS <br /> SIG ATURE OF APP - 1V <br /> Electronic Information:Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City u5f— ❑ Unit 1 �q <br /> 2. <br /> ❑ Unit 2 <br /> 3. <br /> 4. Unit 3 <br /> 5. <br /> 6. <br /> ❑ unit <br /> 7. <br /> $ ❑ Unit 5 <br /> 9. <br /> 10. ❑ Unit6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES ` <br /> O UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITYNEHICLE N <br /> ❑ QTHER 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 13 MOTEL/HOTEL ❑ PUMPER TRUCKIYARD/CHEM TOILETS <br /> 13 TATTOO/BODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> 0 MEDICAL WASTE FACILITY ❑ 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$95.00 deposit prior to review. <br /> EHD USE ONLY <br /> i m <br /> EHDAI$ 6 511612007 <br />