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bCT-3-2010 09:40A FROM:CEOPHR - 'ENU 2095690295 T ' 640138 P.P_ <br /> t�ATMtEIVED EHD LOG NUMBER <br /> ��}Q SAN ,10AQUIN COUNTY€. U� Q ENVIRONMENTAL HEALTH DEPARTMENT <br /> I WilhoW01 dt:' UH 600 East Main Street, Stockton, CA 95202-3029 <br /> P�RM�-QSERViGES Tefephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org d <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: ferle a _ O N BUSINESSIAGENCY: ! <br /> ADDRESS: –77 ave,,^idvde' CitylStatelzip 4 <br /> PHONE(t): G PHONE(2): FACSIMILE: 0 <br /> TEN ATIVE'APPOINTMENT DATE: Time: <br /> { Ioaso allow 10 business days from date of application submittal-'Tentative only-must be confirmed) <br /> HECK Ox TO EXPEDITE REQUEST-$1105 �ORCIIECK ON �REQUE�STPROCESSED FEE(CASH IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE I— O <br /> Electronic Infprmatlon: ❑ List❑Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Stroot# eet StrName City <br /> - �i—.. .. . ._ - [] Unit 1 <br /> 2. ---- © Unit 2 <br /> 3 <br /> 4 .�. Un <br /> 200 <br /> 5. <br /> 4)hIt 4 <br /> O <br /> 7. <br /> Unit 5 <br /> _ ❑ Unit 6 <br /> 10, <br /> Specific Date Range of Information Requested:From to <br /> fid+ ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> �JNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYNEHICLE <br /> THER CLEANUP&TE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> E�VNDERGROkJNO TANK(MONITORINGIREMOVAL) ❑DOG KENNEL ❑DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTELIHOTEL 0 PUMPER TAUCKIYARDICHEM TOILETS <br /> ❑TATTOolBODY PIERCING - ❑POOL/SPA C]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-5:OOPM - EXCLUDING HOLIDAYS, <br /> 1. List up to ten addresses in the space above. Select the type(s)of files frorril the fist 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$105 deposit prior to review. <br /> EHD USE ONLY <br /> EHD 48.06 8104106 PUBLIC RECORDS RELEASE APP FORM <br /> I <br /> I <br /> tI (i <br />