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Jun 15 2009 2: 58PM CR_ 5104``9170 P. 1 <br /> DATE RECEIVED —ND LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> `_01elephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov. <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPItIANT: I BUSINESS/AGENCY: <br /> ADDRESS; !\p0 � �.S �l tl l l CitylStatefZip _ �- 1�tp{Lo be <br /> PHONE(1): �U PHONE(2): FACSI LE: <br /> TENTATIVE"APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-'Tentative only-must be confirmecE <br /> CHECK BOX TO EXPEDITE REQUEST-$106 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSNESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS _ _ EHD USE O`:1LY <br /> Street X Street Name City <br /> Unit 1 <br /> . � <br /> � - �� ,.J : ❑ <br /> 1 <br /> 2. Unit 2 <br /> 3. <br /> 4. Unit 3 <br /> s ------ ❑ <br /> Unit <br /> 7. \\,' <br /> Unit 15 <br /> 8. <br /> 9. <br /> 10. <br /> 1 1 <br /> Specific Date Range of Information Requested: From <br /> �J ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENTOLID WASTE FACILITY/YE!_CLE } <br /> rAZ" ER CLEANUP SITE(NON LOP) ❑ FOOD FACILITYASTE TIRE ERGII TANK(MONITORINWREMOVAL) 171DOG KENNEL AIRY ARDOUS WASTE GENERATOR 11CHICKEN RANCH L]WASTEWATER TREATMENT LANT <br /> IEREO PERMITTED FACILITY ❑ MOTEL)HOTEL ❑ P MPER TRUCK(YARDICHE TOILETS <br /> TATTOOIBODY PIERCING ❑ POOLISPA ND USE APPLICATION srws <br /> ❑MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PEII RECORDS ARE AVAILABLE FOR RENEW - MONDAY-FRIDAY 8:00 AM-5:00P1A - EXCLUDING F1C=IDAYS. <br /> 1. List up to ten addresses in the space above. Select the type(s)of files from the list above by checking thmappropriate <br /> box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the address indicated wove. Address <br /> ranges will not be accepted—for additional assistance with file addresses,contact the EHD. Application=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 appr-ximatety 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 alliplication may be <br /> submitted when the file is available. <br /> 4. Any file not returned in the some condition as released will be reorganized by EHD staff at the expense of—,he applicant. <br /> Future file reviews by the same applicant may require a $105 deposit prior to review. <br /> EHD USE ONLY <br /> EHD 48-06 8!04108 PUBLIC RECORDS-:ELEASE APP FORM <br />