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DATE RECEIVED EHD LOG NUMBER <br /> �u1� r r� � SAN JOAQUIN COUNTY <br /> J L� ENVIRONMENTAL HEALTH DEPARTMENT <br /> li I1:I 600 East Main Street, Stockton, CA 95202-3029 <br /> I 0 X008 Telephone; (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ d3 <br /> �F 7 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: � 1 BUSINESSIAGENCY: .Cyr'y- .' <br /> ADDRESS: _ � L-I fl a—e-&A; lo1 L SL-i( °I,i R;�I <br /> PHONE(1): W go-_sax 5 PHONE(2): FACSIMILE:�1/h 4917 - <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow ton business days from date of application submittal-"Tentative only-must be confirmed) <br /> CHECK BOX TO EXPEDITE REQU T-$98 00 E(CASH OR CHECK ONLY)-REQUEST PROCESSED IN THREE BUSINESS DAYS <br /> SIGNATURE OF APPLICANT - DATE <br /> Electronic information: ❑ List❑ Map-Description. <br /> FILE ADDRESS EHD USE ONLY <br /> Strom tk Stroat Name City � O Unit f <br /> 2. 'Zb `a W04WL"A Unit <br /> 3- ),�bS - <br /> 4. 10 j- <br /> nit S <br /> S 0J <br /> 6 a0 s Ao- It 4 <br /> 7. cLc,-!sel- f �')9 / <br /> 8 ❑Unit 3 <br /> 9. <br /> 10- ❑Untt e <br /> Speclflc Data Range of Information Requested:From M10 to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 13 HOUsINO ABATEMENT In SOLID WASTE FACILITYfVEHICLE <br /> OCHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY O WASTE TIRE <br /> tWUNDEROROUND TANK(MONITORINWREMOVAL) 17 DOG KENNEL 13 DAIRY <br /> 19 HAZARDOUS WASTE GENERATOR O CHICKEN RANCH ❑WAaTEWATERTREATMENT PLANT <br /> O TIERED PERMITTED FACILITY ❑MOTELIHOTEL 0 PUMPFRTRUCKIYARDIGHEM TOILETS <br /> 0 TATroo/BODY PIERCING ❑POOUSPA 13 LAND USE APPLICATION SITES <br /> 0 MEDICAL WASTE FACILITY 17 OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORD®ARE AVAILABLE FOR REVIEW-MONDAY-FRIDAY$.00 AM-$:ooPM -EXCLUDING HOLIDAYS. <br /> 1. List up to ten addresses in the space above. Select the types)of flies from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(209)484-0188 or mall to the above address. Address ranges will <br /> not be accepted-for additional assistance with file addresses.contact the EHD. Applications received after 3:00 pm will <br /> be processed the next business day. <br /> 2. The EHD will notify the applicant If any EHD flies exist. An appointment for review will be confirmed approximately ten <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 /> a. A file that Is actively being worked on by the EHD staff may not be Immediately available for review. A new application <br /> may be submitted when the file Is avallable. <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$98.00 deposit prior to review. <br /> EHD USE ONLY <br /> END 4"d r0IMj <br /> PUBLIC:RE RDS RELEASE APP FORM <br /> L00/LOoz XVj 9d � VL 8007,/90/90 <br />