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9 <br /> DATE RECEIVED 0 EHD LOG NUMBER <br /> SAN a,IOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: q BUSINESS/AGENCY: <br /> ADDRESS: CITY/STATE/ZIP: c� <br /> PHONE (1): 20f PHONE (2): OPi X��R 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 R�EUEST 125 FEE(CASH O,R`OR K ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANDATE 101,/71/ <br /> Electronic Information: ElList❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑Unit 1 <br /> 1. <br /> 2. <br /> El Unit 2 <br /> 3. <br /> 4. <br /> ❑Unit 3 <br /> 5. <br /> 6. <br /> ❑Unit 4 <br /> 7. <br /> 8. <br /> ❑Unit 5 <br /> 9. <br /> 10. <br /> ❑ Unit 6 <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 /> ❑OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL ❑DAIRY <br /> AZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> IERED PERMITTED FACILITY ❑MOTELIHOTEL ❑PUMPER TRUCK/NARD/CHEMICAL TOILETS <br /> ❑TATTOO/BODY PIERCING ❑POOL/SPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑COMPLAINT RECORDS ❑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 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$125 deposit prior to review. <br /> i <br /> U� rur POM ping <br /> EHD 48-06 LIJ 811111 <br />