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DEPT. OF TOXIC SUBS. Fax:916-255-3696 Sep 18 2008 10:46am P001/001 <br /> DATE RECEIVE _ 1-HD LOG NUMBER <br /> r>' <br /> D6 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ". ' 4in� Telephone: (209)468-3420 Fax: (209)464-0138 Web: Www.sjgov-ora/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> RIIIMIr ' <br /> APPLICANT: e+13 ,e IIP t� BUSINESS/AGENCY: <br /> ADDRESS- `�Sr;sc, C-t j City/statelzip <br /> PHONE(1): `1 z-`LJ -1)S;-S-S' PHONE(2): FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: GC,+- -L--=CrY_ Time: <br /> (Please allow 10 husinass days from data of application submittal-*Tantative only-must be confirmed) <br /> 13 CHECK BOX TO EXPEDITE REQUEST 4105 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT "1.p GATE 9 1 K)41S- <br /> Electronic Information: ❑ List❑map.–Description: <br /> FILE ADDRESS EHO USE ONLY <br /> strgot Street Name City <br /> [ Unit 1 <br /> 7 VZ Li 7 <br /> 2. unit2 <br /> i <br /> 3. <br /> 4. Unit 3 <br /> Unit 4 <br /> 6. <br /> 7. <br /> ❑ Unit 4 <br /> 8. je <br /> 9• Unit 6 <br /> 10. <br /> Specific(Yate Range of Information Requested From 12IS-1 to l �� <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILE$ <br /> la'UNDERGROUND TANK(UST)CLEANUP SITE(LOP) C]HOUSING ABATEMENT WSOLID WASTE FACILITY/VEHICLE <br /> IR OTHER CLEANUP SITE(NQN-LOP) ❑FOOD FACILITY RkWASTE TIRE <br /> ® UNDERGROUND TANK(MONITORINO/Rr:MOVAL) 13 DOG KENNEL ❑DAIRY <br /> W HA7ARDOUS WAST)=GENERATOR O CHICKEN RANCH ®WASTEWATER TRPATMENT PLANT <br /> ®TIERED PERMITTED FACILITY 0 MOTELIHoTEL ❑PUMPERTRUCK/YARD/CHEM TOILETS <br /> ❑TATTOOIBODY PIERCING El POOLISPA LAND USE APPLICATION SITES <br /> ❑MEDICAL WASTE FActl,rrY 0 OTHER(PLEASE SPECIFY) <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 wll'I not be accepted-for additional assistance-With'file addresses,Contact the FI-10. 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 EMD 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$105 deposit prior to review. <br /> EHD USE ONLY <br /> END 43.05 8104108 PUBLIC RECORDS RELEASE APP FORM <br />