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DATE RECVED EHD LOG NUMBER <br /> \ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue Stockton, CA 95205-6232 <br /> 1 Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION Ell <br /> Y <br /> APPLICANT: P�tQ � ,a QU�nP � BUSINESS/AGENCY: <br /> ADDRESS: , "I' l^�i� t �[ a- AUe- CITY/STATEIZIP: <br /> PHONE(1): Q S-, Z (q PHONE(2): FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑ Unit 1 <br /> 2. ❑ Unit 2 <br /> 3. <br /> 4. nit 3 <br /> 5. <br /> 6. ❑ Unit 4 <br /> 7. <br /> 8. ❑Unit 5 <br /> 9. <br /> 10. ❑ Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYIVEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORING/REMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ❑HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTEL/HOTEL ❑PUMPER TRUCKIYARD/CHEMICAL TOILETS <br /> ❑TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOO/BODY PIERCING ❑COMPLAINT/RESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <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(209)464-0138 or mail to the address indicated above. Address <br /> ranges will not be accepted-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. Anew 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$125 deposit prior to review. ***BOXED AREA-EHD USE ONLY <br /> uwct Veo Q9Q 62 L' Ao --X= aE c-foo CV'Ltk <br /> Records provided by Staff-PPR Complete. Staff Name: rll7;1 I <br /> -EHD-48-06 iy_ ,. jF'!j'; 9/4112 <br />