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07/17/2009 THU 10: 50 FAX (ajgQl/001 <br /> pry,E�T� EI � EHD LOG NUMBER <br /> H SAN JOAQUIN�COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Jul- 2��1 600 East Main St. Stockton, CA 95202-3029 <br /> Telephone; (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> PER <br /> APPLICANT: ,`,�ti �O; �, ale ry,�fir BUSINESS/AGENCY: 4i, Co <br /> ADDRESS., <br /> Cor<i�ol i �4 <br /> ADDRESS: '- DO Q CITY/STATE/ZIP: M.tLU 5 3 r A. C)� <br /> PHONE(1); PHONE(2): FACSIMILE:'�0,�, <br /> TENTATIVE'APPOINTMENT DATE. Time: <br /> (Plaasa allow 10 business days from date of application submittal-`Tentative only-must be confirmed) <br /> ❑CHECK BOX TO EXPEDITE R ESTE$122 FEE ASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT /l�/J��r� DATE �1(IS(If <br /> Electronic Information: ❑List Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Streat# Street Name City ❑Unit 1 <br /> r2l <br /> i �� S•.A:.he --....0.Unit 2 <br /> 3. <br /> 4. <br /> 5 L7 Unit 3 ,y <br /> 6. ✓✓ <br /> Unit 4 <br /> _7� _ <br /> ❑Unit 6 <br /> 0, <br /> ❑Unit 6 <br /> 10. <br /> Specific Date Range of Information Roqucstcd: From lo <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ®UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITY/VEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑DOG KENNEL ❑DAIRY <br /> ❑HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTELIHOTEL ❑PUt4i,ER TRUCKIYARDICHEMICAL TOILETS <br /> TATTOO/BODY PIERCING ❑POOL/SPA ❑LAND USE APPLICATION SITES <br /> [] MEDICAL WASTE FACILITY ®OTHER(PLEASE SPECIFY) F,t.��(S�Yp';i v7 e S(-Dro-t-0- <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR 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 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 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 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 appllcatlon 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 /> EHD USE ONLY <br /> EHD 46-06 <br /> 07129110 <br />