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DATE RECEIVED EHD LOG NUMBER <br /> (� SAN JOAQUIN COUNTY � <br /> MRD E C E� V�/](�;E D ENVII70l`TMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br /> AUG 2 2 2006 Telephone: (209)468-3420 Fax: (209)464-0138 Web: ,Z!57 <br /> ENVIRONNIENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> PFRM1T/SFRV1 ,P <br /> APPLICANT: jfA_t�,A–/ e C—/- (A BUSINESS/AG'E'NCY: <br /> � <br /> ADDRESS: T T i •�c�_S�� 61i_ <br /> PHONE(1): &%'�^�jl 17 PHONE(2): 95--1–G_3 ( l 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-$95.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLIC /`1 DATE <br /> UNIT DISTRIBUTION ❑ Unit 1 ❑ Unit 2 ❑ Unit 3 ❑ Unit 4 ❑ Unit 5 ❑ Unit 6 ❑ Other(electronic/lists/maps) <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City <br /> 2., <br /> 3 <br /> 4. <br /> 5. <br /> 6. <br /> 7 <br /> 8. t <br /> 9. <br /> 10. <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYNEHICLE <br /> 0 OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY 13 WASTE TIRE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL E7 DAIRY <br /> HAZARDOUS WASTE GENERATOR O CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑MOTEUHOTEL ❑PUMPER TRUCK/YARD/CHEM TOILETS <br /> 13 TATTOO/BODY 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-5: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 <br /> appropriate box(es). At least one file type MUST be selected. Fax to(209).464-0138 or mail to the address <br /> indicated above. Address ranges will not be accepted—for additional assistance with file addresses, contact <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 confirmed <br /> approximately ten (10) days after receipt of application. The files will be held for a maximum of five business <br /> days for review. Appointments 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 will be reorganized by EHD staff at the expense of the <br /> applicant. Future file reviews by the same applicant may require a$95.00 deposit prior to review. <br /> r <br /> :, �wJ <br /> —� <br /> EHD 48-06 11 <br /> 8/1106 <br />