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DATE RECEIVED <br /> SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> a <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br /> Telephone: (209)468-3420 Fag: (209)464-0138 Web: wNvw.sjgov.or ehd <br /> . PUB , <br /> LIC RECORDS RELEASE APPLICATION <br /> APPLICANT: ; <br /> ADDRESS: , -�,'S INEE5/AGENCY: <br /> PHONE <br /> HONE(2): <br /> TENTATIVE"APPOINTMENT DATE: FACSIMILE <br /> � <br /> (Please allow 10 business days from date of application submittal-*Tentative onlyme: <br /> CHECK BOX TO EXPE -must be confirmed) <br /> REQUEST-$95.00 FEE(CAS CHECK ONLY)-REQUEST PROCESSED IN 3 B SINESS DAYS <br /> SIGNATURE OF APPLICANT _ .. <br /> DATE O Q <br /> Electronic Information: ❑ List❑ Ma <br /> Map—Description: <br /> FILE ADDRESS <br /> Street# Street Name EHD USE ONLY <br /> I. 3S 7� - city <br /> 2. S/C 7—c>-) 3—f9 ElUnit 1 <br /> 3. Unit 2 <br /> 4. <br /> 5. Unit 3 <br /> 7, Unit 4 <br /> 9. ElUnit 5 <br /> 10. ❑ Unit 6 <br /> --------------- <br /> Specific Date Range of Information Requested:From <br /> to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ZL UNDERGROUND TANK(UST)CLEANUP SITE LOP ❑ <br /> MOTHER CLEANUP SITE(NON-LOP ( ) HOUSING ABATEMENT <br /> UNDERGROUND TANK(MONITORING/REMOVAL ❑SOLID TIRE FACILIT&EHICLE <br /> ❑FOOD KENNEL WASTE TIRE <br /> HAZARDOUS WASTE GENERATOR ) ❑ DOG KENNEL ❑DAIRY <br /> Td TIERED PERMITTED FACILITY ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TATTOO/BODY PIERCING ❑ MOTEL/HOTEL ❑PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ MEDICAL WASTE FACILITY ❑POOL/SPA_ KL-AND USE APPLICATION SITES <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILAB�L-0Ey1 <br /> FOR RREyy E SPECIFY)����•�� L, � <br /> 1. List Up t0 ten addresses in the Space above. Select the MONDAY-FRIDAY 8.00 AM-S:OOPM - EXCLUDING HOLIDAYS. <br /> bOx(eS). At least one file type MUST be selected. Fax to 09)464-0138 or mOf files from ail to the ddress indie list above by cated the appropriate <br /> ranges will not be accepted—for additional assistance with file addresses,contact the EHD. ed above Address <br /> 3:00 pm will be processed the next business day. Applications received after <br /> 2. The EHD will notify the applicant if any EHD files exist. An appointment <br /> days after receipt of application. The files will be held for a maximumof five bus n slsl days for review. Appointments <br /> should be scheduled accordingly, approximately ten(10) <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$95.00 deposit prior to review. <br /> EHD USE ONLY <br /> END E48"16 9/13t2. - - <br />