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llZDATE RECEIVED <br /> � SAN O QUIN COUNTY EHD LOG NUMBER <br /> ENVIRONMEN A HEALTH DEPARTMENT <br /> 600 East Mai St Stockton, CA 95202-3029 <br /> .00T sir Z0 Telephone: (209) 468-3420 (209)464-0138 Web: www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: 4�4/( VAMb (&W�,— BUSINESS/AGENCY:_ <br /> ADDRESS: -6111 Y/1Jt p l/ v` C <br /> p ��7q 9 f-__ ON CITY/STATE/ZIP: &29tj tj <br /> PHONE(1): 12�- 37-7--!.'.^TCt S PHONE(2): <br /> TENTATIVE'APPOINTMENT DATE: FACSIMILE: <br /> (Please allow 10 business days from dae of aPPlicabon submttal Time: <br /> 'Tentative only- <br /> must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# SSttre�et.N`atm�er� c� �ciitty ❑Unit s <br /> T' 1 <br /> 570T l..i`TW <br /> 3. Unit 2 <br /> 4. <br /> S. Unit W'"1 <br /> 6. V / <br /> 7 — --- - ._ Unit4D <br /> 8. <br /> Unit 5 <br /> 9. <br /> 10. <br /> unit 6 <br /> Specific Date Range of Information Requested: From — to �'Z <br /> �y 0 —2411 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> .f'SI UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT XrSOUD WASTE FACNTYNEHICLE <br /> 'OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY WASTE TIRE <br /> ®UNDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL ❑DAIRY <br /> ®HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> IERED PERMITTED FACILITY ❑MOTEUHOTEL ❑PUMPER TRUC KNARDICHEMICAL TOILETS <br /> ❑TATTOO/BODY PIERCING ❑POOLISPA LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY JKCOMPLAINT RECORDS MOTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILAALE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List u0 to ten addresses In the space above. Select the type(s)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$125 deposit prior to review. <br /> EHD 4606 <br /> &1/11 <br />