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DATFRECEIVE=D EHD tOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> I 600 East Main St. Stockton, CA 95202-2708 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/e <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> Ik APPLICANT: 0) A21'` 1'T�o p-;j2h-s BUSINESSIAGENCY:- \__5(01Q�� <br /> 1 ADDRESS: �c:,vxc S-(7 �C,G �(,� �:. ITYISTATEIZIP <br /> PHONE(1): 6 �1 PHONE 1z1; FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> CHECK BOX TO EXPEDITE REQUEST-$115.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT Mc-...r (( S Of CCLL4 SC I 'S Q [(�t4TE <br /> r ��c�.F i c�cxJev <br /> Electronic Information: ❑ List ❑ Map—Description: <br /> FILE ADDRESS NLY <br /> EHD <br /> Street# Street Name City ti <br /> I ❑ Unit 1 <br /> Adl <br /> 4 1 fir. 1�7 E " <br /> 2. 5S 1' Ijzex Unit2. <br /> 3. <br /> 4. `° �` `UInt 3 <br /> 5. ;< <br /> 6. <br /> El Unit 4 <br /> t%�7�LC �J Co,.c.�c CF1Z. _ - a���--�`'~t--�� <br /> ❑ Unit 5 <br /> 62 <br /> 9. �C�n (rYti �� �.C' ❑ Unit 6 I <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> i <br /> ❑ UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT 0 SOLID WASTE FACILITYIVEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑WASTE TIRE <br /> ❑ UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR M CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOO/BODY PIERCING ❑ POOL/SPA LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> i <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW - MONDAY-FRIDAY 8:00 AM-5:00PM - EXCLUDING HOLIDAYS. 1 <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 be held 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$115.00 deposit prior to review. <br /> EHD USE ONLY <br /> ***If you need further assistance please contact Diane Martinez @ (209)468-3425 directly. Thank You*** <br /> C <br /> EHD 48-06 <br /> 8701!2009 <br />