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M <br />am <br />LI <br />E <br />DATE ETVED <br />`T �7 SAN JOAQUIN COUNTY EHD LOG NUMBER <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 />ADDRESS: <br />PUBLIC RECORDS RELEASE APPLICATION <br />dNESS/AGENCY: <br />CITY/STATEIZIP: <br />PHONE (1). tWI—'A"`u� jPIHONE(2): FACSIMILE:0)p -s�ZD OV <br />TENTATIVE* APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application submittal-*TentaSve only -must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST -$125 FEE (CASH OR CHECK ONLY) -REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT <br />DATE <br />Electronic Information: ❑ List ❑ Map— Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />it1 <br />Sheet# <br />Street Name <br />city <br />I. <br />I <br />iNl 1{M i md1 <br />❑Unit 2 <br />2. <br />3. <br />Unit 3 <br />4' <br />5. <br />❑ Unita <br />6. <br />7. <br />(] Units <br />8. <br />9. <br />El Unit 6 <br />10. <br />Specific Date Range of Information Requested; From to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />] UNDERGROUND TANK (LIST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE FACILITYNEHICLE r <br />] OTHER CLEANUP SITE (NON -LOP) El HOUSING ABATEMENT ❑ WASTE TIRE (Q .{y I.Q5 /0 <br />] UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ FOOD FACILITY ❑ DAIRY(� 1 <br />ABOVEGROUND TANK rz ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER TREATMENT PLANT <br />%HA7ARDOUS WASTEIHAZARDOUS MATERIALSV, ❑MOTELIHOTEL ❑ PUMPERTRUCKIYARDICHEMICAL TOILETS <br />TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br />] TATTOOIBODY PIERCING ❑ COMPLANTIRESPONSE 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 types) of files from the list above by checking the appropriate <br />box(es). At least one file type MUST be selected. Fax to (203)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. ***BOXED AREA - EHD USE ONLY"* <br />