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FEB-4-2010 11:47A FROM:GEOPHAS U 2095690295 LM40138 P.2 <br /> N. GNUMBER���7F N�CFIv � <br /> TI�r� SAN JOAQUIN COUNTY <br /> RVn <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> FEB 0 4 2010 600 East Main Street, Stockton, CA 95202-3029 � <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd ) <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION �^// <br /> PER APPLICANT:I ^ . Gl'Y eF BUSINESSIAGENCY: W0 <br /> ADDRESS: .� 937 AP'lre_�44'M /rYe- CltylState/Zip /✓✓rf-W'-J7n <br /> PHONE 11): 5 dZQ 3 PHONE(2): FACSIMILE:869 O.Z�Ki <br /> TENTATIVE`APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from data of application submittal--Tentative only.must b0 conflrmyd),' <br /> CHECK BOX TO EXPEDITE REQUEST•$105 FEE CASH OR CHECK 05Y)-REQUEST PROCESSED IN a BUSINE <br /> SIGNATURE OF APPLICANT : `� DATE <br /> Electronic Information: ❑ List❑Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street f Street Name City <br /> 2.- 8'a'0O._ .5' S 'P_G.716F....... � �� ❑ Unit <br /> 3. <br /> 4. <br /> 6. nit 4 <br /> 6. <br /> T' Unit 5 <br /> 6. I <br /> 9. r O units <br /> Specific Date Range of Information Requested:From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> NDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 HOUSING ABATEMENT 0 SOLID WASTE FACILITY/VEHICLE <br /> IC.I OTHER CLEANUP SITE(NON-LOP) 0 FOOD FACILITY Cl WASTE TIRE <br /> 'Pr_ <br /> TANK(MONITORINGIREMOVAL) 0 DOG KENNEL C3 DAIRY <br /> 0 HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH 0 WASTEWATER TREATMENT PLANT <br /> 0 TIERED PERMITTED FACILITY O MOTELIHOTEL O PUMPER TRUCKIYARDICHEM TOILETS <br /> 0 TATTOOIBODY PIERCING 0 PDOL/SPA 0 LAND USE APPLICATION SITES <br /> 0 MEDICAL WASTE FACILITY 0 OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW - MONDAY-FRIDAY 8:00 AM-6:OOPM - EXCLUDING HOLIDAYS. <br /> 1. List up to ten addresses In the space above. Select the type(s)of files from the IIsi above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to 12091464-0138 or mail to the address indicated above. Address <br /> ranges will not be accepted-for additional assistance with file addresses,contact the EMD. 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 behold 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$106 deposit prior to review. <br /> EHD USE ONLY <br /> EHD 45-06 8/04108 PUBLIC RECORDS RELEASE APP FORM <br />