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SAN JOAQUIN COUNTY tHU LULi NijMt54 <br /> n° ECF3\VF.DD ENVIRONMENTAL HEALTH MPARTMENT <br /> 304 Last Weber Avenue, 3rd ton, CA 95202-2708 <br /> VAR (VI— 2005 Telephone; (209)468-3420 Fax (209)464-013 Web: www.sigov.org/ehd <br /> ENVIRONMENT HEALTH PUgZ,YC RECORDS RELEASE APPLICATION <br /> APPLICANT: ' <br /> �j BINESS/AGENCY: <br /> ADDRESS:p^�/J,�_� �/t /4r�1�*if,lltn.•.. /.� /r <br /> PHONE(1); PHONE(2)_ �'� f �, FACSIMIL ' <br /> TENTATIVE"APPOINTMENT DATE: <br /> (Please allow 10business days from date of application submittal-'Tentat/ve on y mmu t be confirmed) <br /> C1 CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE(CASH OR CHECK ONLY)—REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> UNIT DISTRI6UTlON C3 Unit 1 ❑ <br /> Unit 2 0 Unit 13 nit 4 dUnit 5 CIUnit 6 ❑ Other(electronlcllists/meps) <br /> ,. <br /> FILE ADDRESS <br /> Street# Street Name City EHD USE ONLY <br /> 2. <br /> 3. f <br /> 4. <br /> 6. <br /> 7. <br /> 10.-LIZ <br /> .f p• <br /> Specific Date Range of Information Requested.From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> d UNDERGROUND TANK(UST)CLEANUP SITE(LOP) d HOUSING ABATEMENT ❑SOLID WASTE FACILITY/VFaiICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑FOoo FACILITY d WASTE TIRE <br /> UNDERGROUND TANK(MONITORINWREMOVAL) O DOG KENNEL ❑DAIRY <br /> ❑HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TATTED PERMITTED FACILITYTATTOO0 MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> LJ❑MEDICAL <br /> WAS00Y PIERCING ❑POOUSPA ❑ LAND USE APPLICATION SJITE,S� <br /> MEbICAL WASTE FACILITY i(OTHER(PLEA$E SPECIFY) A Z 4 /(/ rf�pr�fL � f <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILA13LE FOR REVIEW - MONDAY-FRIDAY 8:00 AM-5:00PM - EXCLUDING HOLIDAYS. 4 <br /> 1. List up to ten addresses In the space above. Select the types} of files from the list above by checking the <br /> appropriate box(es). At least one file type MUST be selected. Fax to (209)464-0138 or mall 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 /> EHO A8-02.006 <br /> 17/23!04 - <br />