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12/30/2005 08;11 FAX 510 420 92 CAMBRIA 16 001 <br /> Vn t C I�CI.Ct V CU <br /> + _ SAN JOA UIN COUNTY EHD LOG NUMBER <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> u 'J 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 I �/� <br /> Ur- L[)l�5 Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> n i, c ` HEALTH PUBLIC RECORDS RELEASE APPLICATION ` ./�+ <br /> AP fl&'AW 6l Liz _ <br /> / - BUSINFRCIAcEurv. /✓.__.�_ f� kl?�L <br /> ADDRESS: 5`700 rynG+-�S .ilY�/,' .Sv i7E �,•�•^�ua r=nt w.�eet! <br /> PHONE(1): S1 /Zo 33r4.9 PHONE(2): <br /> FACSIMILE: $-/a _ qpm <br /> TENTATIVE*APPOINTMENT DATE: If II A3 Zoo 6, l _ <br /> (Please allow 10 business days from date of application submittal-•Tentative onlym must beconfirmed) <br /> 13 CHECK BOX TO EXPEDITER UEST-$9340 FEE(CASH OR CHECK ONLY)- <br /> REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT T � <br /> DATE (�J.i6ElL S0 z..o S <br /> UNITDISTRIBUTION ❑Unit1 ❑ Unit2 ❑Unit3 ❑ UnIt4 ❑ Unit5 ❑ <br /> Unit6 E3 Other(eleetronidlists/maps) ' <br /> FILE ADDRESS <br /> Street Street Name city EHD USE ONLY <br /> 1. 23010 E <br /> 2. 2515 <br /> 3. <br /> 4. <br /> 5. <br /> 6. <br /> 7. <br /> Specific Date Range of Information Requested:From ALL 45LEX, to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ..+� NDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING) ABATEMENT <br /> OTHER CLEANUP SITE NON-LOP SOLID WASTE FACILT'NEHICLE <br /> ❑FOOD F13ACILITY EI WASTE TIRE <br /> yy ( <br /> UNDERGROUND TANK(MONITORING/REMOVAL) RDOG KENNEL ❑DAIRY <br /> ,M iAZA cDOUS WASTE GENERATOR 0 CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY - ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑MEDICALTATroo/WAS PIERCING ❑POOLfSPA ❑LAND USE APPLICATION SITES <br /> O MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW- MONDAY-FRIDAY 6:00 AMS:OopM - 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 <br /> appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the address <br /> Indicated above. Address ranges will not be accepted—for additional assistance with file addresses,contact <br /> the EHD.Applications received after 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 <br /> approximately ten (10)days after receipt of application. The files will be held for a maximum of five business <br /> days for review. Appointments 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 <br /> application may be 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 <br /> applicant. Future file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> EHD da-0t-006 I <br /> 7HM05 <br />