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9 <br />0 - <br />DATE R EIVED I 1 SAN JOAQUIN COUNTY <br />! ENVIRONMENTAL HEALTH DEPARTMENT <br />G 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />J Telephone: (209) 468-3420 Fax: (209) 464-0138 Web. wvvw.sjgov.org/ehd <br />ADDRESS: <br />PUBLIC RECORDS RELEASE APPLICATION <br />CITY/STATEMP: <br />EHD LOG NUMBER <br />94.5 <br />PHONE (1). jW)- `6"-,!Z 'jPHONE(2): FACSIMILE: i5yl _T20 -qty <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- $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 />Street# <br />Street Name <br />City <br />1. <br />IAve.iw <br />lM ; �2. <br />7 NJ�'t 2 <br />3. <br />Unit 3 <br />4. <br />5. <br />❑ Unit <br />5. <br />T. <br />❑ Unit 5 <br />8. <br />9. <br />❑ UnhO <br />10. <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL HEALTH DEPARTMENT FRES <br />] UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY - ❑ SOLID WASTE FACILNYNEHICLE <br />F <br />]OTHER CLEANUP SRE (NON -LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE (0?�j /0,-/0,-( �• <br />] UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ FOOD FACILITY ❑ DAIRY ) 7-15 -( 7 <br />ABOVEGROUND TANK tz ❑ CHICKEN RANCH[DOG KENNEL ❑ WASTEWATER TREATMENT PLANT <br />%HAZARDOUS WASTEIHAZARDOUS MATERIALSV , ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEMICALTOILETS <br />TIERED PERMITTED FACILITY ❑ POOUSPA ❑ LAND USE APPLICATION SITES <br />] TATTOO/BODY PIERCING ❑ COMPLAINTIRESPONSE 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_ "BOXED AREA - EHD USE ONLY'*" <br />