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DATE RECEIVED EHD LOG NUMBER <br /> 177"1- [ 6 SAN JOAQUIN COUNTY <br /> '-Y I A/ Fr � <br /> f, - I I I�' <br /> '\�-7 L__j L "I <br /> ; ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: WWW.sjgov.or'e <br /> PPQ FOIT/�J: PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESS/AGENCY:AGENCY: <br /> ADDRESS: City/State/zip S'rz16 L-r-,, <br /> PHONE(1): -7� e4?06 PHONE(2): —FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$105 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: E] List El Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street 0 Street Name City E] Unit I <br /> 2. ❑ Unit 2 <br /> 3. <br /> 4. ❑ Unit 3 <br /> El Unit 4 <br /> 6. <br /> 7. El Unit 5 <br /> 8. <br /> 9. <br /> Unit 6 <br /> 10. <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 0 UNDERGROUND TANK(UST)CLEANUP SITE(LOP) E3 HOUSING ABATEMENT 13 SOLID WASTE FACILITYIVEHICLE <br /> 13 OTHER CLEANUP SITE(NON-LOP) 13 FOOD FACILITY 0 WASTE TIRE <br /> 0 UNDERGROUND TANK(MONITORING/REMOVAL) E3 DOG KENNEL 13 DAIRY <br /> E3 HAZARDOUS WASTE GENERATOR 0'C'HICKEN RANCH E3 WASTEWATER TREATMENT PLANT <br /> 13 TIERED PERMITTED FACILITY M MOTEUHOTEL 0 PUMPER TRUCK/YARD/CHEM TOILETS <br /> 0 <br /> TATTOO/BODY PIERCING 13 POOL/SPA 13 LAND USE APPLICATION SITES <br /> 0 MEDICAL WASTE FACILITY 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 ton 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(2 09)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 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 /> EHD 48-06 8/04/08 PUBLIC RECORDS RELEASE APP FORM <br />