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DATE RECEIVEDEHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> RECEIVEDENVIRONMENTAL HEALTH DEPARTMENT !A 9 9 7 <br /> 600 East Main St. Stockton, CA 95202-2708 <br /> AN 04 201�elephone: (209) 468-3420 Fax: (209) 464-0138 Web: www•.sjgov.org/ehd <br /> 0-MIRONM NTALHEAUH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT:C' BUSINESSIAGENCY: <br /> ADDRESS: CITY/STATE/ZIP:T�C[jAXP ! <br /> PHONE (1): 4C06- 7 � - PHONE (2): 4%--S L4-177 FACSIMIL <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 REST-$115.00 FEE SH OR CHECK ONLY)-REQUEST PROCESSED IN13 BUSINESS DAYS <br /> SIGNATURE OF APPLICANTOW <br /> Electronic Information: ❑ List ❑ Map- Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City <br /> F1 Unit 1 <br /> 1 - ©CM <br /> _2. otafL_ <br /> Unit 2 <br /> 3. <br /> 4' ca O V � ❑ Unit 3 <br /> 5 L <br /> 6' 0 C-T. 11JOV 67c- ❑Unit 4 <br /> 7. <br /> 8. <br /> ❑Unit 5 <br /> 9. CLI --z <br /> 10. �[� \j ❑Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> I ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> I ❑UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYIVEHICLE <br /> t ❑OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORINGIREMOVAL) d DOG KENNEL ❑DAIRY <br /> ❑HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH DIVASTIEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTELIHOTEL KPUMPER TRUCKNARDICHEMICALTo{LETS <br /> ❑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-5:00PM(EXCLUDING HOLIDAYS) <br /> l <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 END. 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$115.00 deposit prior to review. <br /> EHD USE ONLY <br /> ***If youneed further assistance please contact bione Martinez direct) @ (209)468-3425. Thank You*** <br /> 4 <br /> FHR dN_!1F <br /> I <br />