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___ @D ZF9RECEIVED 0 + EHD LOG NUMBER <br /> lI 11EV� �� V �D� SAN.TAL HEAUIN COUNTY <br /> l� �"/ I� ENVIRONMENTAL HEALTH DEPARTMENT 2 ,�aq7, <br /> `� Z��6 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br /> A!1(; ? Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.orgVehd <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESS/AGENCY: <br /> ADDRESS: '� 3 <br /> PHONE( ) ��(( �j//���l,PHONE( ): O C.� FACSIMILE:S O <br /> TENTATIVE'APPOINTM�N•fUTE: Time: <br /> (Please allow 10 busine ays from date f application submittal-'Tentative only-must be confirmed) <br /> CHECK BOX TO EXPEDITE T-$9 0 FEE C O HECK ONLY)-REQUEST PROCESSED IN fUSINISS DgYS <br /> SIGNATURE OF APPLICANT DATE � D b <br /> UNIT DISTRIBUTION ❑ Unit 1 ❑ Unit 2 ❑ Uni nftW�p nits O Unit G ❑ Other(electronicAists/maps) <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Y1 <br /> Street Nam Cit_ <br /> 1' 0vLG <br /> 2. 1 1 <br /> 3. ( (( <br /> 4. tl 1 <br /> 5. _ <br /> 6. <br /> 7. <br /> 8. <br /> 9. <br /> 10. - <br /> Specific Date Range of Information Requested: From to a <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES to <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT El SOLID WASTE FACILITY/VEHICLE 4" <br /> OTHER CLEANUP SITE(NON-LOP) E3 FOOD FACILITY 17 WASTE TIRE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL ❑DAIRY <br /> 13 HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH I O WASTEWATER TREATMENT PLANT <br /> Cl �7-MOTEL/HOTEL PUMPER TRUCK/YARD/CHEM TOILETS <br /> �. <br /> TIERED PERMITTED FACILITY Ir 0 <br /> TATTOO/BODY PIERCING a POOLISPA ❑LAND USE APPLICATION SITES <br /> O MEDICAL WASTE FACILITY 10 OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW - MONDAY-FRIDAY 8:00 AM5:00PM - 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 <br /> appropriate box(es). At least one file type MUST be selected. Fax to(2091464-0138 or mail to the address <br /> indicated above. Address ranges will not be accepted-for additional assistance with file addresses,contact <br /> the EHD.Applications received after 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 <br /> approximately ten (10)days after receipt of application. The files will be held for a maximum of five business <br /> days for review. Appointments 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 <br /> application may be 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 <br /> applicant. Future file reviews by the same applicant may require a$95.00 deposit prior t eview. <br /> EHD <br /> 611/06 <br />