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4 DATE RECEIVEHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> 3�a �`"° ►�-� `� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 952.05-6232 <br /> �)T g' hone: (2_09) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> BLIC RECORDS RELEASE APPLICATION <br /> � � <br /> f{jl1�S �j�r j=�} BUSINESS/AGENCY:��/4(dICl/VIL <br /> API T: <br /> ADDRESS: Co f� n< l CITY/STATE/ZIP: UUtc,S/Ze,�S 6)f'o e 610-5-fS <br /> PHONE(1): (4j�c�� ��t �{ l PHONE (2): FACSIMILE: 9 <br /> TENTATIVE*APPOINTMENT DATE: rii/j� Time: iV <br /> (Please allow 10 business days from date of application submittal-`Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST_7-$125 FEE(CASH CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESSD Y76— S <br /> SIGNATURE OF APPLICANT �1'�11r- -j� f DATE (2 /007/-_Y_ <br /> of <br /> Electronic Information: ❑ List❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑Unit 1 <br /> 2. /rte /� Unit 2 !% <br /> 3. <br /> 4. {� f` / Unit 3 <br /> 5. <br /> 6. <br /> Unit 4 <br /> 7. <br /> 8. <br /> El Unit 5 � <br /> 9. <br /> 10. <br /> ❑ Unit 6 <br /> Specific Date Range of Information Requested: From J,�/i/. QG'o�' to Qil L SCd4 y <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES / <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) [:]MEDICAL WASTE FACILITY F-1SOLID WASTE FACILITYIVEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) <br /> EI ABATEMENT [:]WASTE TIRE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) F1FOOD FACILITY ElDAIRY <br /> ABOVEGROUND TANK [-]CHICKEN RANCH/DOG KENNEL WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTEMAZARDOUS MATERIALS E]MOTELIHOTEL PUMPER TRUCK/YARD/CHEMICAL TOILETS <br /> TIERED PERMITTED FACILITY ❑POOL/SPA 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. 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$125 deposit prior to review. "'BOXED AREA-EHD USE ONLY <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 48-06 9/4112 <br />