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UA I E RECEIVED <br /> SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> ENVIhoNMENTAL HEALTI-I DEPARTMENT <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sigov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: .r �� BUSINESS/AGENCY: .� "M' <br /> ADDRESS: 5 �J S C_^ CITY21-DC-1� I��U STATE <br /> PHONE(1): �—� '�PHONE2 <br /> ( ) FACSIMILE: <br /> TENTATIVE"APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> CHECK BOX TO EXPEDITER QUE T-$93.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANTA 4,4_a Z A, DATE <br /> Electronic ❑ List ❑ Ma cri <br /> Information P- ption <br /> FILE ADDRESS <br /> Street# Street NameCity EHD USE ONLY <br /> 1. <br /> 2. W ❑ Unit 1 <br /> 3.4. ❑ Unit 2 <br /> C ❑ Unit 3 <br /> s. <br /> 7 Unit 4 <br /> 9. ❑ Unit 5 <br /> 10. <br /> innAl—, <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 0��,,(( <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 13 HOUSING ABATEMENT 13 SOLID WASTE FACILITYNEHICLE <br /> _0THER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY JKWASTE TIRE <br /> 11 UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL O DAIRY '(/ <br /> 11 HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> 11 TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEMICAL TOILETS <br /> ❑ TATTOO/BODY PIERCING ❑ POOUSPA ❑ 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 <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 4806 <br /> 10131!2006 <br />