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_pI�IEF�EGEIVEQ—_ EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> j' Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov"Or /eh <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: Y7r_�_ 1 <br /> 4�4r!!Yb'Ak BUSINESSIAGENCY: <br /> ADDRESS: \u4fA4 7---Ae- C.4y g;-A_ CITY/STATE/ZIP: -aiA6C (pYdx�w (k J�`7b <br /> PHONE(1):514-3 65 r a C- 3 PHONF(2): qio FACSIMILE: I& <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 REQUEST.$115 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# Street Name City ❑Unit 1 n / <br /> 2. cS t i nit 2 <br /> 3 yZ53 <br /> 4. <br /> " 3 <br /> 5. <br /> 6' nit <br /> 7. <br /> or <br /> $' ❑Unit 5 <br /> g• i _ <br /> 10. <br /> ❑Unit <br /> Specific Date Range of Information Requested: From 19 7s' to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ZUNDEROROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYNEHICLE <br /> j BOTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> FANDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL ❑DA1RY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTELIHOTEL ❑PUMPER TRUCK/YARD/CHEMICAL TOILETS <br /> CJ TATTOOIBODY PIERCING ❑POOLISPA AND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑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 un 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)464-0136 or mill 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 proceesed 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. Anew application maybe <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 deposit prior to review. <br /> 5. If you need further assistance,please contact Diane Martinez,at(209)468-3425. <br /> EHp USE ONLY <br /> EHD 48-06 <br /> a�anos <br />