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DATE RECEIVED <br /> SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> � let) ENRONMENTAL HEALTH DEPARTAT <br /> Re600 East Main St. Stockton, CA 95202-3029 <br /> �Ay 12 2�\1 Telephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/eh <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> BUSINESSIAGENCY:1l�/,� <br /> ADDRESS 2i/j (,),f t � Pc r CITY/STATE/ZIP:_ C Ir I (o 2- <br /> PHONE (1 y/fe J r, �- / PHONE(2): E/L 1?, rt fty FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: <br /> Time: <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> ❑CHECK BOX TO EXPEDITE REQUEST-$1 E(CASH R CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE �jl Zf1 <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name <br /> City <br /> ❑ Unit 1 <br /> 2. s ( I <br /> 3, ❑Unit 2 <br /> 4. <br /> 5, nit 3 <br /> 6. <br /> 7. nit 4 <br /> 8. <br /> 9. ❑ Unit 5 <br /> 10. <br /> Specific Date Range of Information Requested: From ❑Unit 6 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES to e <br /> UNDERGROUNDTANK(UST)CLEANUP SITE(LOP) ^ <br /> ( ) ❑HOUSING ABATEMENT El SOLID WASTE FACIUTYNEHICLE Y <br /> OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY <br /> UNDERGROUND TANK(MONITORING/REMOVAL) <br /> MONITORING/REMOVAL A. ❑WASTE TIRE �Ji t 3 ` <br /> HAZARDOUS WASTE GENERATOoo���\ ❑CHICKEN RANCH <br /> )Y\ El DOG KENNEL El DAIRY <br /> TIERED PERMITTED FACILITY ' [:1 WASTEWATER TREATMENT PLANT <br /> ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TATTOOIBODY PIERCING ❑POOLISPA <br /> ❑ MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) ❑LAND USE APPLICATION SITES <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List un 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$122 deposit prior to review. <br /> EHO USE ONLY <br /> EHD dB-06 <br /> 07/29/10 <br />