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DATE RENED I w SAN JOAQUIN COUNTY END LOG NUMBER . <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> OR- Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.orglehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANTtc JD � BUSINESS/AGENCY: <br /> ADDRESS: i.�' Ken MI��StnnP �� CITY/STATEiZIP:C-'.� ► t�w�t /b- <br /> PHONE(1): t�1 ' g� —� �jPHONE(2): FACSIMILE: <br /> zT <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 DATE <br /> Electronic Information: ❑List❑Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> street# Street Name City it1 ` <br /> 2. 7 vOtQ' / <br /> ❑Unit 2 J <br /> 3. 1 <br /> 4' Unit a <br /> 5. <br /> S' ❑Unit �(q <br /> 7. <br /> g- <br /> �units <br /> 9. <br /> 10. 1- a <br /> Unite , <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILRYNERCLEr <br /> ❑OTHER CLEANUP SITE(NON-LOP) [I HOUSING ABATEMENT ❑WASTE TIRE /jl .�/�$5 /�( I �• <br /> ❑UNDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRY •N/1/•-,-)�j-(7 <br /> ABOVEGROUND TANK p` ❑CHICKEN RANCH/DOG KENNEL []WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTHHAZARDOUS MATERIAV, ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICALTOILIETS <br /> TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOO113ODY PIERCING ElCOMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> 1. List un to ten addresses in the space above. Select the type(s)of foes 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 flies 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 /> gfn <br /> i ... <br /> ROMEO <br /> .. . . - <br /> 17 c_bTdrow`tieff b Staff P]�R(arn Tg �sfra —s <br /> Y p <br /> — - <br /> EHDM46 - : . <br /> az4nz <br />