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DATE RECEIVED EHD LOG NUMBER <br /> 110'a j f Z f 0,- SAN JOAQUIN COUNTY <br /> 1 ( ENVIRONMENTAL, HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-3429 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION \- <br /> APPLICANT: BUSINESS/AGENCY: Ee"61 <br /> e51�5 t-e-20O <br /> ADDRESS:ADON\ C, C)TYISTATEfZIP: Li, <br /> PHONE(1): <-j5"- ,_ 50I-j Q S(p PHONE(2): FACSIMILE: -6-Co- -jaA - <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business ays from date of application submittal-'Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQU ST 25 F E(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: 571771 Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City Unit 1 <br /> 1. <br /> 2. <br /> ❑Unit 2 <br /> 3. <br /> 4. <br /> 5. ❑Unit3 <br /> 6. <br /> ❑Unit 4 <br /> 7. <br /> L9. <br /> ElUnit 5 <br /> ElUnit6ific Date Range of Information Requested: ' From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FRES <br /> ❑UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYNEHICLE <br /> ❑ <br /> OTHER'CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORINGIREMOVAL) ❑DOG KENNEL ❑DAIRY <br /> ❑HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILETY. ❑MOTEUHOTEL ❑PUMPER TRUCKWARDICHEMICAL TOILETS <br /> ❑TATTOOIBODY PIERCING ❑POOIJSPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑COMPLAINT RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 ANI-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, i <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. <br /> EHD 4a-05 <br /> a��rtt <br /> 1 <br />