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F E'f- 9VF.0 SAN JOAQUIN COUNTY <br /> EN' '.ONMENTAL HEALTH DEPARTIV <br /> 3 1 2011 6�East Main St. Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.org/ehd b <br /> ENvIRONMENTAL HEAM PUBLIC RECORDS RELEASE APPLICATION <br /> ..T egnVICES <br /> APPLICANT: tCy�1- n C� l< BUSINESS/AGENCY: L�R <br /> Ly <br /> Y <br /> ADDRESS: P (1 i3 ` CITY/STATE/ZIP: 'pL �O,!� <br /> PHONE (1): ).0�71 PHONE (2): ,;QJi_ 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(CASH-QR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE 31 1 l <br /> Electronic Information: ❑ List ❑ Map— Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City Unit 1 <br /> -- <br /> 2. <br /> 3. -- — - — - -- <br /> El <br /> 2 <br /> 4. _ -- <br /> 5. Unit 3 <br /> 7. — <br /> 7. — — — --- — Unit 4 <br /> 8. <br /> Unit 5 <br /> 9. <br /> 10. <br /> it <br /> Specific Date Range of Information Requested: From (_ � \0 �1 0 e,V S to t��-Qy_t_ <br /> ENVIRONMEN AL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) HOUSING ABATEMENT ❑SOLID WASTE FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) 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 ❑MOTELIHOTEL ❑PUMPER TRUCKNARD/CHEMICAL TOILETS <br /> TATTOO/BODY PIERCING ❑POOLISPA ❑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-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List up to ten addresses in the space above. Select the types)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$122 deposit prior to review. <br /> EHD USE ONLY <br /> EHD 48-06 <br /> 07129/10 <br />