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01/24/2005 15:34 CLRYTOk JUP 4 12094640138 N0.839 PO <br /> I., — "U.' 1'' `" vc"'�L'� LrJVIRONMENTAL HEALTH PAGE 01 <br /> GATE RECEIVED crlu Lw Ivulv�o�� <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTALEALTH DEPARTMENT — - --- -- <br /> 304 East Weber Avenue, 3'8 Floor,Stockton, CA 95202-2708---- <br /> Telephone:(209)468-3420 Fax: (209)464-0138 Web:www,sjgov,org/Chd <br /> 4 �n�5 <br /> Eta_ �h11r_NT HEALTH PU�LTC RECORDS RELEASE APE'LICATZON <br /> P,���c��T BUSINESS/AGENCY: <br /> TENTATIVE`APPOINTMENT DATE: Time: <br /> (Pi2ase allow to business days from date of appllcaGon submittaf-'r7"t'jV0 or'ly-must tre confirmed) <br /> AM-JC EHECK ONLY <br /> CK BOX TO EXPEDITE REQUEST-$95.00 FEE(CASH OR C )-REQUEST PROCESSED 1N 3 BUSINESS DAYS <br /> SIGNATURE;OF APPLICANT DATE <br /> UNIT DI$TRIl3UTION 0 Unll i Unit 2 Unit 3 Unit 4 Q Unit 5 d Unit 6 Cl Other(clectronlcAists/maps) <br /> FILE ADDR_ ES EHD USE ONLY <br /> �4,, <br /> gtreet M 5treel Nameg S-0 W tart m ma- e-a-h' r T— <br /> / 3. 1_S sig <br /> 7. <br /> r <br /> 9. <br /> Specific Date Range of Information Requested:TFrorn t0 m <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES } <br /> Q HOUstNG AGATEMENT ❑SOUD WASTE FACR.ITYNEIOCLE <br /> �}'UNOERGaOUND TANK(UST)GL£AHVp SITE(LOP) o Foot)FACILITY O VYA�1E TIDE <br /> &MTNER CLEANUP SITE(N°N•LOP) 0 Foot K AciLrNNLL C),DSA-SY <br /> CrNDEROROUND TANK(MONITOaING/RETdOVAL) ❑ CHICKEN RANcr IEA Y�ASTEWATER TREATMENT PLANT <br /> Z;'_HA2ARDOU9 WASTE GENEAMA 0 MOTFL[HOTEL 0 PUMPER TRUCKIYARDICHEM TOILE=T'S �r <br /> QVrFRED PERMIYTCD FACILITY O POO�PA O LAND usE APPLICiT10N SITES <br /> O TATTOpIfa0VY PiTRONG <br /> 0 MEUCAL WASTE FACILITY M OTN6R(PLEASE SPeCIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILARLE FOR REVIEW- MONDIP <br /> AY-FRAY 8:00 AU-6:0(" �(CLUt7ING HOUpAYS. <br /> 1. List up to ten addresses in the space above. Select the typos)of files from the list above by checking the <br /> appropriate box(es). At least one file type MUST be selected. Fax to 09 A6+1 0138 or mail to the address f. <br /> ;ndi� sated above. Address ranges will not be accepted–for additional assistance with file addresses,Con <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 held For a maximum of five business <br /> mconfirmed <br /> approulmately ten (10)days after receipt of application, The files <br /> days for review. Appointment-- 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 returned in the same condition as released V1111 be teOrganized by END staff at the expense of the <br /> applicant- Future file reviews by the same applicant may require a $93.00 deposit prior to review. I <br /> i <br /> ENt?db•C 2.ODd <br /> 11:23104 I <br /> I <br />