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10/21/2009 WED 16: 08 FAX 2094682999 SJC Public Works 121001/001 <br /> I � <br /> D� EHD LOG NU BER SAN .�OAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> UC t 2 1 2009 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www,sigov.org/ehd <br /> NPER ITISE rICESHEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: f 't. p '/O el BUSINESS/AGENCY: <br /> ADDRESS: _[ �Q /�, Nn �� ,b ��� Citylstate/Zip <br /> PHONE(1): �`�g -y�8—30�S� 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 RE T-5105 FEE C SH OR HECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT r`-- DATE e O <br /> Electronic Information: ❑ List❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City <br /> nit 1 <br /> 2• SQ G f n ��� Unit �\ <br /> ii 4. f6 C� Y C.CJgG� r� 'L.� OCL .0�nit3 <br /> I 5. 6-'(0 r v` e- g,.v6. <br /> nk 4 poill <br /> ckrf 1- 00 <br /> 7. WC / Unit 5 <br /> 9. ❑ Untt6 <br /> 10. <br /> Specific Date Range of Information Requested:From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> . YNDERGROUNO TANK(UST)CLEANUP SITE(LOP) KHOUSING ABATEMENT ❑SOLID WASTE FACILITY/VEHICLE <br /> ;RMTHER CLEANUP SITE(NON-LOP) %4-FOOD FACILITY ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL ❑DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTEL/HOTEL LIMPER TRUCK/YARD/CHEM TOILETS <br /> ❑TATTOO/BODY PIERCING ❑POOL/SPA ❑LAND USE APPLICATION SITES <br /> i ❑MEDICAL WASTE FACILITY Cl OTHER(PLEASE SPECIFY) <br /> i <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILADLE 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 END. 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 field 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 8104/08 PUBLIC RECORDS RELEASE APP FORM <br />