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f t� <br />DATE RECEIVED EHD LOG NUMBER <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: BUSINESS/AGENCY: <br />ADDRESS: <br />PHONE (1): 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 - $95.00 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE <br />Electronic Information: ❑ List ❑ Map — Description: <br />FILE ADDRESS EHD USE ONLY <br />Street # Street Name City ❑ Unit 1 . <br />1. <br />2. ❑ Unit2 <br />3. <br />4. ElUnit 3 <br />5. ❑ Unit 4 <br />6. <br />7. <br />❑ UnitS' <br />8. <br />9• ❑ Unit 6 <br />10. <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) 0 HOUSING ABATEMENT 13 SOLID WASTE FACILITYNEHICLE <br />❑ OTHER CLEANUP SITE (NON -LOP) E3 FOOD FACILITY 13 WASTE TIRE <br />13 UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL 13 DAIRY <br />13 HAZARDOUS WASTE GENERATOR ® CHICKEN RANCH E3 WASTEWATER TREATMENT PLANT <br />TIERED PERMITTED FACILITY ® MOTEL/HOTEL E3 PUMPER TRUCK/YARD/CHEM TOILETS <br />13 TATTOO/BODY PIERCING ❑ POOL/SPA 17 LAND USE APPLICATION SITES <br />MEDICAL WASTE FACILITY 13 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 $96.00 deposit prior to review. <br />EHD USE ONLY <br />EHD 4MG 9/13/2006 <br />