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DATE RECEIVED EHD LOG NUMBER <br /> C <br /> - r SAN JOAQUIN COUNTY <br /> ��l� ENVIRONMENTAL HEALTH DEPARTMENT <br /> , 304 East Weber Avenue,3'd Floor,Stockton,CA 95202-2708 <br /> [_ 05 Telephone:(209)468-3420 Fax:(209)464-0138 Web: ww.sjgov.org/ehd 11q15 <br /> j�p,LTH vvPUBLIC R <br /> ECORDS RELEASE APPLICATION <br /> AP' LUCANT: - L�GLMu itMAf�C_ BUSINESS/AGENC <br /> Y- ClGitdiUyrl GNU_00 lCw <br /> ADDRESS: l l y H S 4� 1G.- U CX1QL )12-- o1 tt q 4 4 ltC)� S r 0.10 1Z 1 <br /> PHONE(1): (4 bO)y4.51 PHONE(2):r FACSIMILE:. L y 3 c) `i S1-3 4 7 8 <br /> TENTATIVE*APPOINTMENT DATE: rune: <br /> (Please allow 10 business days from date of application submittal-'Tentadve only-must be confirmed) <br /> CHECK BOX TO EXPEDfTE REQUEST-$93.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT rn DATE ad <br /> UNIT msTitwunON ❑ Unit 1 ❑ Unit 2 ❑ Unit 3 ❑Unit 4 0 Unit 5 ❑ Unit 6 ❑ Other(electronicltistshnaps) <br /> FILE ADDRESS END USE ONLY <br /> Street Street Name City <br /> 2- } ,'1 1 <br /> 3. <br /> 4. <br /> 5. <br /> 6. • <br /> 7. ` <br /> 8. <br /> 9. <br /> 1 d. <br /> Specific Date Range of Information Requested:From F"al: I C-S )` to C_f) <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> XUNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HouSNG ABATEMENT ❑SOLID WASTE FACILI YIVEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) 17 FOOD FACILITY 13 WASTE TIRE <br /> UNDERGROUNDTANKluomiTORlNG/REMOVAL) ❑DOG KENNEL O DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANcN 0 WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMnTED FACILITY ❑MOTELIHOTEL 13 PuuPERTRUCKIYARD/CHEMToiLErs <br /> C3 TATTOOIBODY PIERCING C3 POOLISPA E3 LAND USE APPLICATION SITES <br /> ❑MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPEC" <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REYIEw - MoNDAY-FRIDAY 8:00 AM-6:00pM - EXCLUDING HOLIDAYS. <br /> 1. List up to ten addresses in the space above. Select the type(s)of files from the list above by Necking the <br /> appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the address <br /> indicated above- Address ranges will not be accepted-for additional assistance with file addresses,contact <br /> the END.Applications received after 3:00 pm will be processed the next business day. <br /> 2. The END will notify the applicant if any END fries 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 END 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 END staff at the expense of the <br /> applicant Future file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> EHD ae-0s�os <br /> V"M5 <br /> 6'd SLto-L9t, (08b) d06:ZL 50 OZ deS <br />