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UHittttutivtu SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> Raj ECEN SCD ENANMENTAL HEALTH DEPARTMOT <br /> 600 East Main St. Stockton, CA 95202-2708 <br /> DEC O 7 2009 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.orLR 9 O <br /> 0 <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> t 1 WuLalVIV .w <br /> APPLICANT: j �;`1ty�U.Qt1c BUSINESS/AGENCY: Aljua iced L& l-ol,.ve..uYT,-Y <br /> ADDRESS: t i l S\(,, 20 j CITY/STATE/ZIP: .� c �}ay. C& yS 2 i <br /> PHONE (1): P-061- LI6-7- IDOID PHONE (2): a07- /p0) - FACSIMILE: dO L <br /> TENTAT/VE`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 $115.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATEZZ <br /> IElectronic Information: ❑ List❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name city ❑Unit 1 <br /> 1. 1f West I�az 1 AvMiALc � �ae.� Ia� SC) <br /> 2. <br /> 3. ElUnit 2 <br /> 4. \� <br /> ❑Unit 3 <br /> 5. <br /> 6. <br /> nit 4 <br /> 7. <br /> 8. <br /> — ❑ Unit 5 <br /> 9. <br /> 10. <br /> ❑ Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILRYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ElFOOD FACILITY ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORINGIREMOVAL) ❑DOG KENNEL ❑DAIRY <br /> ❑HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTELMOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TATTOOIBODY PIERCING ❑POOLISPA <br /> ❑ 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-5:00PM(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 (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 /> END USE ONLY <br /> **"If you need further assistance Please contact Diane Martinez direct) @ (209)468-3425. Thank You' <br /> can nn nc <br />