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DATE RECEIVED <br /> e D SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> E E�� v �U ENVIRONMENTAL HEALTH DEPARTMENT <br /> AUG2�Q1 600 East Main St. Stockton, CA 95202-2708 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sigo r <br /> APPLICANT: <br /> ANT: T HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: Q .1CSi(/E <br /> ADDRESS: p, L3 OX _R-7'0 J BUSINESS/AGENCY: <br /> A S3 e2 <br /> PHONE(1): — p PHONE(2): 40Z —/6 FACSIMILE: g—zs g <br /> TENTATIVE*APPOINTMENT DATE: <br /> (Please allow 10 business days from date of application submittal-*Tentative only) must be confirmed) <br /> � CHECK BOX TO EXPEDITE REQU <br /> -$98-00 E(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT <br /> DATE - 2Z—p7 <br /> Electronic information: <br /> ❑ List❑ Map—Description: <br /> f FILE ADDRESS <br /> Street# Street Name EHD USE ONLY <br /> 1 city <br /> Unit t <br /> 2 CL E N <br /> 3. <br /> S Cl E.rIENT <br /> 4. <br /> 5 Unit 3 <br /> 6. <br /> Unit 4 <br /> 7. \ <br /> 8. ❑ Unit 5 <br /> 9. . <br /> 10. Unit 6 <br /> Specific Date Range of Information Requested: From <br /> to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑ UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ OUSlNG ABATEMENT <br /> ❑ OTHER CLEANUP SITE(NON-LOP) SOLID WASTE FAClLITYNEHICLE <br /> FOODI <br /> ❑ NDERGROUND TANK(MONITORJNGIREMOVAL) 0 DOG KENNEL Y ❑WASTE TIRE <br /> VAZARDOUS WASTE GENERATOR ❑ DAIRY <br /> ❑TIERED PERMITTED FACILITY d CHICKEN RANCH WASTEWATER TREATMENT PLANT <br /> ❑TATTOOIBODY PIERCING ❑ MOTEL/HOTEL ❑PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ MEDICAL WASTE FACILITY ❑POOLISPA IK LAND USE APPLICATION SITES <br /> ❑OTHER(PLEASE SPECfFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW - MONDAY-FRIDAY 8:00 AM-5:00PM - EXCLUDING HOLIDAYS. <br /> I <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 behold 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$95.00 deposit prior to review. <br /> EHD USE ONLY <br /> "**If ou need further assistance lease contact Diane Martinez @ (209)468-3425 direct! Thank You*�* <br /> H❑48.64 9114!2006 <br />