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L'NVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202-2708. 'L <br /> IN Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/chd <br /> AUG 5 2005 ((// <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APP ERI F BUSINESSIAGENCY: eWrS_I1ES/ 62e-)CU 1,7'/,A/ <br /> ADDRESS:-- P. O . P/�iJX 3'�qt TiRLr�c�G A !yC s'-y/ <br /> PHONE(1): 4 2� PHONE(2): FACSIMILE:_!o�o g•-ZSgg <br /> TENTATIVE`APPOINTMENT DATE: Time: <br /> (Please allow 10 busingafrom date of application submittal-*Tentative only-must be confirmed) <br /> �� ❑ CHECK BOX TO EXPEDITE RE593.00 F OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> -`SIGNATURE OF APPLICANT DATE <br /> UNIT DISTRI13UTION ❑ Unit 1 ❑ Unit 2 ❑ Unit 3 ❑.Unit 4L❑ Unit 6 ❑ Unit 6 ❑ Other(eleetronicllistslmaps) <br /> FILE ADDRESS <br /> Streeter Street Name city EHD USE ONLY <br /> 1• J41k7114 STFmiE4"4_ LOn/ <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> 5. <br /> 7. <br /> 8. <br /> 9. <br /> 10. 1 1 <br /> Specific Date Range of Information Requested: From to <br /> y(-/UENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> M NDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOVSWG ABATEMENT ❑SOLID WASTE FACILMfVEHICLE - <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑FOOD FAcam ❑WASTE TIRE <br /> .❑ UNDERGROUND TANK(MONnORINGIREMOVAL) ❑DOG KENNEL 0 DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MdTELIHOTEL ❑PUMPER TRUCKIYARDICHEM TOILETS <br /> d TATTOOIBODY PIERCING- -❑POOLISPA - ❑LAND USE APPLICATION SnES <br /> ❑ MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT REcORDs ARE AVANIBLE FOR REVIEW- MONDAY-FRIDAY 800 AMab0P1A - 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 <br /> appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the address <br /> indicated above. Address ranges will not be accepted-for additional assistance with file addresses,contact <br /> the EHD.Applications received after 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 <br /> approximately ten(10)days after receipt of application. The files will be held for a maximum of five business <br /> days for review. Appointments 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 <br /> application may be submitted when the file is available. <br /> 4. Any file not retumed in the same condition as released will be reorganized by EHD staff at the expense of the <br /> applicant. Future file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> .y .j ti•_ <br /> � 1 � r <br /> EHD U42-0 - <br /> 11123M <br />