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�UAItKtutivtu SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> EARONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-2708 <br /> DEC 0 7 2009 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: WWW.sjgov.orLN 9O <br /> 0 <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> 1 LII1YI11/VLIIVIVLV -f1-.� �) -- f- /� <br /> APPLICANT: j LGCLGC { ;11-t � � BUSINESS/AGENCY: A0'Vr�t ed � ZZ i` p„wg V� <br /> ADDRESS: 431 s�UI �a CITY/STATE/ZIP: s L [ { C14- g/SZIS <br /> PHONE (1): P-0- I-16-7- f oOb PHONE (2): CID q- kbi - FACSIMILE: 9 Lilo 1— 111 g <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 REQU T-$115.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS m <br /> SIGNATURE OF APPLICANT DATE Z q <br /> r+ <br /> ' Electronic Information: ❑ List❑ Map-Description: <br /> IV <br /> 0 <br /> FILE ADDRESS EHD USE ONLY ca <br /> Street# Street Name city ❑Unit 1 <br /> 0 <br /> 2. <br /> 3 E]Unit 2 <br /> 4. \� <br /> 5 ❑Unit 3 <br /> IN <br /> 6. <br /> nit 4 <br /> 7. <br /> 8. <br /> 9 - ElUnit 6 <br /> 10. <br /> ❑ Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> rUNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYIVEHICLE <br /> i OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORINGIREMOVAL) ❑DOG KENNEL ❑DAIRY <br /> ❑HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH <br /> ❑ ❑WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY <br /> ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TATTOOIBODY PIERCING ❑POOLISPA. <br /> F1 MEDICAL WASTE FACILITY El LAND USE APPLICATION SITES <br /> ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> 1. List up 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 It 0) <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 direct) @ (209)468-3425. Thank You*** <br /> FMtI dgJlf <br />