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07/02/2009 15.'55 209-668-2598 <br /> PAGE 01/01 <br /> ,.__DATE Rr;cr;jvEp. <br /> SAN JOAQUIN COUNTY EHD LOG NUMIaER <br /> L <br /> L I <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> J::-!L -0" 40 2609 600 East Main Street, stor-kton, CA 95202-3029 <br /> Telephone.• (209) 468-3420 Fax: (209)464,0138 Web, <br /> i!:"�k I T Www,$jgov.org1e <br /> T.'i 2 D, PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT- - TV <br /> 4C OUSINESSIAUENCY: <br /> ADDRESS: <br /> City/state/zip 7—UgLock' <br /> PHONE(1)! PHONE(2): _40-Z <br /> TENTATIVE*APPOINTMENT DATE: �.FACSIMILE: <br /> (Please allow 10 business days from date ata -submitim Time: <br /> only-must be Confirmed) <br /> CHECK BOX TOEXPEDITE RE T 4106 1' Q OR CHECK ONLY)-REQUEST PROCESSED IN z BUSINESS DAY* <br /> SIGNATURE OF APPLICANT 415 DATE <br /> Electronic I nf Ormation: Z <br /> List[I Map-Description: <br /> Street FILE ADDRESS Pmn USE ONLY <br /> Street Name city <br /> 2. <br /> 4. <br /> Unit 3 <br /> 6. <br /> Unit 4 <br /> 7. <br /> 8. ❑ _Ullit 5 <br /> 9. <br /> 10. El Unit t <br /> SPOCIflo Date Range of information ktqUeStod: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 0 WkIOEROROuND TANK(UST)CLEANUPSITE(LQt) 13 HOUSING Aakrr�MPNT <br /> 0 OTHER CUANuF3 SITE(NON-LOP) 13 SOLID WASTE FACIUTYlVEHICLE <br /> 13 UNDERUROUNO TANK(MONITORING/REMOVAL) Cl FOOD FACILITY 13 WASTE TIRE <br /> 0 HAZARDOUS WASTE GENERATOR 13 DOG Krimmz4 13 DAIRY <br /> OTIERED PERMITTED CHICKEN kANCHTED FACILITY b E3 WASYLNYATER TREATMENT PLANT <br /> 13 TATT60SQOY PiRpeiNc MorEujqoTr;L 13 PUMPER TRucKIYARD/CHEM TOILETS <br /> 13 MEDICAL WASTE FACILITY 13 C3 OTMER(POOL/SPAPLEASC S pEC(py) VtANC�USE APPLICATION SITES <br /> WELL AND SEPTIC PERMIT RMQRI*ARE AVAILABLE FOR REVIEW - MOMZ3AY-FAFDAyR;00AM_6:00PM - EXCLUDING HOLIDAYS, <br /> Z, List Up to ten addresses in the space above. select the typels)of files from the list above by checking the appropriate <br /> box(es). At least one file type MUST be Selected. Fax to 20111 1 U4-ofu or <br /> ,R��#1_1�am '.,�to the address Indl <br /> ranges will not be accepted-for additional assistance with fife Oted above. Addre5s <br /> 3,00 Pm will be processed the next businessduo-ss9s.Contact the LHD. Ap i' <br /> Bay. <br /> P[cations received after <br /> 2. The EHD Will notify the applicant if any EHD files exist An appointment for review will be confirmed <br /> days after receipt Of application. The files will be held for a med approximately ten(10) <br /> should be scheduled accordingly, Maximum Of.five business days for review. Appointments <br /> 3. A file that is actively being worked on by EHD staff May hot be immediately available for review. A new application may be <br /> submitted when the file is available. <br /> 4. Anyfile not returned In the Same Condition as <br /> Future file reviews by the same applicant may released V411 be reorganized by EHD staff at the expense of the applicant, <br /> y require a$105 deposit.prior to review. <br /> EHD USE ONLY <br /> �HD 0-06 8104105 <br /> PuB.L10,Rff-C-0-R-D-S RELEASE APP FORM <br />