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_ YII 61YI611 1 <br /> i <br /> ��''" 559517 <br /> DAN JO T-954 P.02/05 F-713 <br /> 51_( -, AQUIN COUNTY <br /> E...�IRONMENTAL HEALTH DEPARTM`NT <br /> ,jl.N 0 6 LA 08 600 East Main Street, Stockton, CA 95202-3029 <br /> "' <br /> EN X111-");i11 E , .;`yl!� Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.a /e7 <br /> ry' . ' ' "�` PUBLIC RECORDS RELEASE APPLICATION <br /> i tr.1ip !;i ;r� ,r! <br /> APPLICANT:SWN -f �-i Ltt&NDWTIV! BUSINESS/AGENCY: �ViQ/\' <br /> ADDRESS: L ln, D ST <br /> 5 TE c ry OD G I (�L 1 / �G <br /> PHONE(1):MCI)— � Q PHONE(2): � / �& Q <br /> — O) (P�J <br /> TENTATIVE*APPOINTMENT DATE:_(III°I I Q FACSIMILEC� <br /> (Please allow ten business days from date o application submittal-'Tentative onlylmmust be confirmed) ' <br /> r7 CHECK BOX TO EXPEDITE REQUEST-$98.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN THREE BUSINESS DAt <br /> SIGNATURE OF APPLICANT 16 41 <br /> -` X,—�_ DATE L/t4 I D�- <br /> Electronic Information: ❑ List ❑ Map - Description: <br /> FILE ADDRESS <br /> Street# Street Name EHD USE ONLY <br /> -3 <br /> 1. 6 (� city <br /> nft 1 <br /> 2. 0r •' �sQ U <br /> 3. 0 nit 2 <br /> 4. <br /> S. 2� `o � �nit s <br /> 6. 2f0 �I �����eeeee''''' <br /> 7• (p nit 4 <br /> 8. <br /> 9. nit 5 <br /> 10. �2 W �d Vi V1 NA It Vit C It v1 <br /> Unit 6 <br /> Specific Date Range of Information Requested: From 'l0 <br /> to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITELOP <br /> ( ) Q HOUSING ABATEMENT SOLID WASTE FAGILfTYIVL <br /> OTHER CLEANUP SITE(NON-LOP) HICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL FOOD FACILITY �WASTETIRE <br /> HAZARDOus WASYE GENERATOR DOG KENNEL ❑ DAIRY <br /> TIERED PERMITTED FACILITY ❑GHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> TATTOO/BODY PIERCING MOTEL/HDTEL [D_PUMPER TRUCK/YARD/CHEM TOILETS <br /> MEDICAL WASTE FACILITY t]POOLISPA ►`b'�t <br /> Q OTHER(PLEASE SPECIFY) LAND USE APPLICATION SITES <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 12091 464-0138 or mail to the above address, <br /> not be accepted-fart business <br /> assistance with file addresses,Contact the EHp. AppllCationS received after 3 00 pmewi VIII <br /> 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 a <br /> days after receipt Of appllcation. The files will be held for a maximum of five business days for reviewp oximately ten <br /> should be scheduled accordingly. Appointments <br /> 3. A file that is actively being worked on by the EHD staff may not be immediately available for review. A new application <br /> 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 <br /> Future file reviews by the same applicant may require a$98.00 deposit prior to review. of the applicant. <br /> EHD USE ONLY <br /> EMD 48.08 10129107 77 <br /> PUBLIC RECORnS RELEASE APP FORM <br />