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DATE RECEIVED EHD LOG NUMBER <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main St, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web:.www.sjgov.org/ehd <br />OCTJ <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: 4t4bVA4A-- BUSINESS/AGENCY: few* - m . <br />ADDRESS: All ( M13 r &" (Pr, CITY/STATE/ZIP; W9" (0 CAN 9 915 <br />PHONE (1): 92 5� _ 52.71 t 7q R PHONE (2): FACSIMILE: <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 - $125 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT <br />DATE <br />Electronic Information: ❑ List ❑ Map — Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />❑ Unit 1 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />,UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT <br />Street # <br />Street Name <br />City <br />1 <br />2 <br />•, f dNT <br />ST -0 CX -TOO <br />ZUnit2_ <br />2. <br />❑ CHICKEN RANCH <br />❑ WASTEWATER TREATMENT PLANT <br />TIERED PERMITTED FACILITY <br />3. <br />❑ PUMPER TRUCKIYARDICHEMICAL TOILETS <br />❑ TATTOO/BODY PIERCING <br />❑ POOLISPA <br />J <br />Unit 3 <br />4. <br />COMPLAINT RECORDS <br />MOTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM -5:0013M (EXCLUDING HOLIDAYS) <br />5. <br />` <br />6. <br />7. <br />�. <br />\ <br />Unit 5 <br />8. <br />— <br />—0 <br />U nit 6 <br />10. <br />Specific Date Range of Information Requested: From <br />to(fu <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />,UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT <br />SOLID WASTE FACILITYIVEHICLE �6 <br />'OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />tKWASTE TIRE ti <br />B UNDERGROUND TANK (MONITORINGIREMOVAL) <br />❑ DOG KENNEL <br />❑ DAIRY <br />HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ WASTEWATER TREATMENT PLANT <br />TIERED PERMITTED FACILITY <br />❑ MOTELIHOTEL <br />❑ PUMPER TRUCKIYARDICHEMICAL TOILETS <br />❑ TATTOO/BODY PIERCING <br />❑ POOLISPA <br />LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACIUTY <br />COMPLAINT RECORDS <br />MOTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM -5:0013M (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 $125 deposit prior to review. <br />EHD 48.06 <br />8l1/11 <br />