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RECEIVED V1- SAN JOAQUIN COUNTY <br /> EHD LOG NUMBER <br /> R ENVIRONMENTAL HEALTH DEPARTMENT <br /> S P 0 4 NI2 G� r 3 PP1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephon : (209) 468-3420 Fax: (209)464-0138 Web: www.sigov.org/ehd <br /> Et IvIRONMENTAL HEALTH col <br /> PERMITISERVICES <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> IR I <br /> APPLICANT: 1 t I BUSINESS/AGENCY: <br /> ADDRESS: —t�I Yr0 ?\ CITY/STATE/ZIP: I T <br /> PHONE(1): bLD s3 PHONE(2): FACSIMILE: <br /> TENTATIVE*APPO NTMENT DATE: A pd GTi q/ 12 Time: 1 =cam ► � <br /> (Please allow 1 business days from date of f application submittal-*Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$125 FEE(CASYM PeaJECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLIC NT DATE <br /> Electronic Information: FjListEl Map- Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City 'Innit 1 <br /> F2. <br /> A ❑unit 2 <br /> 3. <br /> 4. pUnit 3 1 <br /> � i <br /> 5. <br /> ,r f <br /> 6. l.l]Unit <br /> 7. !. <br /> 8. ❑Unit 5 <br /> 9. <br /> 10. ❑Unit 6 <br /> Specific Date Range of Informatio Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEA UP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYIVEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) M FOOD FACILITY ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORIN IREMOVAL)V1— ❑DOG KENNEL ❑DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY oe– ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TATTOOIBODY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ©COMPLAINT RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT R CORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> 1. List up to ten addresses ir the space above. Select the type(s)of files from the list above by checking the appropriate <br /> box(es). At least one filepe MUST be selected. Fax to(209)464-0138 or mail to the address indicated above. Address <br /> ranges will not be accepte -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 thesame applicant may require a$125 deposit prior to review. <br /> EHD USE ONLY <br /> EHD 48-06 811111 <br />