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DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> �� Eta . ,RONMENTAL HEALTH DEPARTfWNT <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> p 2 0 LOVelephone: (209) 468-3420 Fax: (209) 464-0138 W :%Wvnjgd. <br /> T- <br /> 0VIFtON"EN-rAL0EALT" <br /> RMI <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: Q:Vfi✓ /V,¢ t,,o r/ BUSINESS/AGENCY: �f�p/�� 7 S SC CC���¢ - <br /> ADDRESS: `FEEL kF _/ Lj,�F- CITY/STATE/ZIP: <br /> PHONE (1): Z - L/�7:fz y3 PHONE (2): FACSIMILE: <br /> TENTAT/VE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-"Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List ❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Narne City <br /> Unit 1 <br /> 2. /7111 f4 MOiv� (NitT /— cr1T�� Unit2 <br /> - — <br /> 3. <br /> 4. <br /> —- - - - - - Unit 3 <br /> 6. <br /> 7. <br /> 8. <br /> ❑ Unit <br /> 9. <br /> 10. <br /> Unit 6 <br /> Specific Date Range of Information Requested: Fromto <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ®UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYIVEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY Q WASTE TIRE <br /> ®UNDERGROUND TANK(MONITORINGIREMOVAL) ❑DOG KENNEL ❑DAIRY <br /> ® HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑MOTELIHOTEL ❑PUMPER TRUCK/YARD/CHEMICAL TOILETS <br /> TATTOO/BODY PIERCING ❑POOLISPA ❑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 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List up to ten aldresses 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$125 deposit prior to review. <br /> EI1D USE ONLY <br /> EHD 48-06 811111 <br />