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DATE RECEIVED SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> p ne: (209) 468-3420 Fax: (209 464-0138 Web: www.s ov.or /ehd <br /> �� ) 19 9 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT:� BUSINESS/AGENCY: <br /> ADDRESS: CITY/STATE/ZIP:yS- ��C,q, <br /> PHONE (1): �1� � � PHONE (2): 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 EXPEDITE REQUEST-$122 FEE( SH R CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT pn I cI DATE <br /> Electronic Information: ❑ List ❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑ Unit 1 <br /> 2. mac, <br /> --- \ �— El Unit 2 <br /> 3. <br /> 4. <br /> ❑ Unit 3 <br /> 5. <br /> 6. <br /> ❑ Unit <br /> 7. <br /> 8. <br /> ❑ Unit..5- <br /> 9. <br /> 10. ❑ Unit 6 <br /> Specific Date Range of Information Requested: From '�Itf7 t 0 to Q / <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES 0SPYC/7b7-7 <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITY E�F((ICLE r--t lJ-f'`{:� <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY F]WASTE TIRE FF`` <br /> NDERGROUND TANK(MONITORINGIREMOVAL) ❑DOG KENNEL ❑DAIRY <br /> AZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑MOTELMOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TATTOOIBODY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY OTHER(PLEASE SPECIFY) Fe `siol� <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 expens he applicant. <br /> Future file reviews by the same applicant may require a$122 deposit prior to review. <br /> ffPS 12M EHD USE ONLY <br /> l� <br /> EHD 4M6 VU <br /> 07/29/10 <br />