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II �' <br /> EHD LOG NUMBER <br /> )ATE REG EIVED/ �� SAN .JOAQUIN COUNTY <br /> � L � [l\J L ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3Td Floor, Stockton, CA 95202-2708 � w <br /> .05 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web : wwwsjgov.vrg/ehd (�® <br /> M`v'friC?MEN1 HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> BUSINESSM SENCY: I` f' <br /> A <br /> ADDRESS: Z�G V '.✓` �` Z- �l� fLv-L : (aU� <br /> RI3 � L <br /> PHONE (1): -2 1 � �� — �� PHONE (2): JL � 7-�" � - ( fie 5 ( FACSIMILE: <br /> TENTATIVE'" APPOINTMENT DATE: _3 �"' G ' Time: <br /> (Please allow to business days from date of application submittal - •7entaflye only - must be cenflmed) <br /> 11 CHECK BOX TO EXPEDITE REQUEST - $93 00 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />.I SIGNATURE OF APPLICANT +� ���""' L'�—. DATE <br /> UNIT DISTRIBUTION ❑ Unit 1 OUnit2 EIUnit3 Unit4 1711LInitS 0 Unite 11 Other (electronicRistsimaps) <br /> FILE ADDRESS EHD USE ONLY - <br /> Street9 Street Name 6;l r, .T ! , city <br /> 1 . � 1 li 1 or< • o ;+ 7 "Ir.) Y11.. �k�crto <br /> C') :.;1 : <br /> 3. 2 �4 J eJ - r �k L v � u�, + Wt <br /> 4. S /til <br /> Tom` <br /> 7. �^ _ <br /> 10, <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ,� ❑ HOUSING ABATEMENT 11 SOLIDWASTE FACIUTYIVEHICLE <br /> ya vNOERGRDUND TANK (UST) CLEANUP SITE (LOP) 0FOOD FACILITY 0WASTE TRE <br /> 13 OTTIER CLEANUP SITE (NON-LOP) t3 DOG KENNEL C3 DAIRY <br /> E] UNDERGROUND TANK (MUNITORINGIREMOVAL) ❑ CHIC KEN RANCH WASTEWATER TREATMENT PLANT <br /> El HAZARDOUS WASTE GENERATOR ❑ MOTELIHOTEL El PUMPER TRUCKNARDICHEM TOILETS <br /> ❑ TIERED PERMITTED FACILITY ❑ POOLI$PA 11 LAND USE APPLICATION SITES <br /> • TATTDOIBODY PIERCING <br /> 11 MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECIFY) <br /> WELLANDSEPTIC PERMIT RFCORDSARE AVAILADLE FOR RENEW 11 MONDAY-Fla OAY8:00AM.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 <br /> appropriate box{es). At least one file type MUST be selected. Fax to (2091464-0136 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 /> i - <br /> EHO 4"24100 <br /> 1114105 <br /> I <br /> Z d 9996-)99 60Z UepV UBA MaKI d99 40 90 9Z qej <br />