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FROM : JODI VANNEMAN FAX NO. : 4154793988 Oct. 08 2010 10:47AM P2 <br /> EHD LOG NUMBER <br /> SAN .IOAQUIN BOUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> U� 0 2010 600 East Main St. Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.oreh F17 <br /> ENVIKUNIVIM I HEALTH PUBLIC RECORDS RELEASE APPLICATION /'��� �Il, <br /> P APPLICANT: BUSINESSIAGENCY:_6 �l �Jld Wh <br /> ADDRESS: ..r�"' CITYISTATE/ZIP: art j <br /> PHONE(1): so • PHONE(2):_3�p�-.F FACSIMILE: <br /> TENTATIVE`APP INTM NT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-•Tentative only-must be confirmed) <br /> ❑CHECK BOX TO EXPEDITE REQUEST.$122 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: I]List❑map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name IL City Unit 1 <br /> 2. �' _ ---- nit 2 <br /> 4. nit 3 <br /> 5_ <br /> 7. w <br /> 8. ... <br /> [)Unit 5 <br /> 9, <br /> 1 O. Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> .;i��TNDFRGROUND TANK(UST)CLEANUP SITE(LOP) Q HOUSING ABATEMENT ❑SOLID WASTE FACILITYNEHICIT <br /> �'OTHI R CLEANUP SITE(NON-LOP) ❑FOOD FACILITY 0 WASTE TIRE <br /> O; UNDERGROUND TANK(MONITORINGIREMOVAL) ❑DOG KENNEL ❑DAIRY <br /> qo Q HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCHASTEWATLR TREATMENT PLANT <br /> ,TIERED PERMITTED FACILITY ❑MOTEL/HOTEL �UMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TATTOO/BODY PIERCING ❑POOL/SPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL,WASTF.FACII,ITY ❑OTHER(PLEASE SPECIFY) <br /> W ELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW_ MONDAY-FRIDAY S:UO Ann-5:ODPM(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)454-0138 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 EHL)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$122 deposit prior to review. <br /> ...._.,.- l_HU USE ONLY <br /> 6140 ad-06 <br /> oms11 0 <br />