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A <br />'RECEIVED SAN JOAQUIN COUNTY EHD LOG NUMBER <br />a,Hil <br />ENOONIVIENTAL HEALTHDEPARTAT <br />600 East Main St. Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />ENVIRONMENTAL t;EALTH <br />PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT:G e1 SCA C CZ BUSINESS/AGENCY: 5E <br />ADDRESS: <br />. m <br />ONE (2): ­ <br />CITY/STATE/ZIP: <br />FACSIMILE: <br />TENTATIVE*APPOINTMENT DATE: _ Time: _ <br />(Please allow 10 business days from date of apprfAation submittal - *Tentative only - must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST- $12 E/C OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT.. L ' 1 / _-- -- DATE'- �j — %— <br />Electronic Information: ❑ List E] Map — Description: <br />FILE ADDRESS EHD USE ONLY <br />Street # Street Name City El Unit 1 <br />2. <br />❑ Unit 2 <br />3. <br />— -- -- <br />---- — Unit 3 <br />4 <br />- --- <br />5. <br />— — <br />ZUIR4 <br />6. <br />7. <br />-- <br />-- — ------ <br />-- - --- __ <br />8. <br />❑ Unit 5 <br />9. <br />❑ Unit 6 <br />10. <br />Specific Date Range of Information Requested: From to A <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />7WIN6ERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITYIVEHICLE <br />;J-D.IHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ WASTE TIRE (� <br />a �-tittt)ERGROUND TANK (MONITORING/REMOVAL ❑ DOG KENNEL ❑ DAIRY <br />ZJ:IAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ WASTEWATER TREATMENT PLANT <br />a -TIERED PERMITTED FACILITV�_ ❑ MOTEL/HOTEL ❑ PUMPER TRUCKIYARD/CHEMICAL TOILETS <br />I TATTOOIBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br />MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-S:OOPM (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 END 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 />UJt VNLY <br />