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07/11/2007 22: 31 2099552230 COUNTY BANK PAGE 01/01 <br /> CrIU -VV IVUIVIGtK <br /> DATE RECEIVI=D SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2709 <br /> Telephone: (209)468-3420 Fax: (209),164-0138 Web- ivVrW.sjgov nrg/ehd <br /> PIT-BLT RECORDS RELEASE APPLICATION <br /> APPLICANT: / BUSINESS/AGENCY: <br /> ADDRESS: <br /> PHONE(1) �� �s �O`1 r� PHONE(2): F �p 7 FACSIMILE ��/ S ;;L,3 D <br /> TENTATIVE"APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-•Tentatfva only-must be confirmed) <br /> C] CHECK BOX TO tD17't hFt: T-595.Q0 (GA 9 G ON '�- QUEST rROCES"D IN 3 BUS ES QAYS <br /> SIGNATURE OF APPLI A T /I x DATE <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> street# Street Name City ❑ Unit 1 <br /> -- ❑ Unit 2 <br /> 2. <br /> 3. <br /> ❑ Unit 3 <br /> 4. <br /> Unit 4 <br /> 6. <br /> 7. p Unit s <br /> 8. <br /> g_ ❑ Unit 6 <br /> 10. <br /> Specific Date Range of information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> M UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑SOLID WASTE PACIUTYNEHICLE <br /> In OTHER CLEANUP 91TE(NON-LOP) 0 FOOD FACILITY ❑WASTE TICK <br /> ❑ UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> A HAZARDOUS WASTE GENERATOR C1 CHIGKI:N RANCH 0 WASTEWATER TREATMENT PLANT <br /> 0 TIGRCD PVRMITTeb FACILITY ❑ MOTEwHOTEL ❑ PUMPER TRUCKlYARD/CNEM TOILETS <br /> 17 TATTOO/BODY PIERCING 0 POOLISPA 17 LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY M OTHER(PLEASE SPECIFY) <br /> WELL AND SaPTIC Pr.RMIT Recopos ARE AVAII AM r PoR 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 il3dicated above. Address <br /> (ranges will not be accepted—for additional assistance with film addresses,contact the EHD.Applications received after <br /> 3:00 pm will be processed the next business day. <br /> 2, Thea EHD will notify the applicant if any END 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 ctaff may not bo immodiateely available for roviow. A nPw 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$93.00 deposit prior to review. <br /> EHD USE ONLY <br /> C - �o <br /> EHD 48-06 9/142006 <br />