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DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY 44 <br /> J" ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-2708 <br /> - Telephone: (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.orYZV <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: if`'C/-n 't 1V A / yi BUSINESS/AGENCY: <br /> 6-(7' <br /> ADDRESS: ` `� V' C7 f—e' D✓'•CITY/STATErZIP <br /> PHONE(1): ��'�`! 4- " L C j 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 $105.00 FEE(C N OR CHECK ONLY)•REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT ' % DATE el- �5 ' �' cI <br /> Electronic Information: ❑ List❑ Map-Description: <br /> n' FILE ADDRESS _ EHD USE ONLY <br /> I` / Street k Street Name city _ ❑ Unit 1 <br /> (h/I� 7. 145 Z <br /> 2. <br /> ❑ Unit 2 <br /> 3. <br /> 4. <br /> 5. IW�"-) ' <br /> 6. Unit 4 <br /> 7. <br /> $ ❑ Unit 5 <br /> 9. <br /> ❑ Unit 6 <br /> 10. <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 0 UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 HOUSING ABATEMENT 0 SOLID WASTE FACILITYNEHICLE <br /> 0 OTHER CLEANUP SITE(NON-LOP) 0 FOOD FACILITY 0 WASTE TIRE <br /> 0 UNDERGROUND TANK(MONITORINGIREMOVAL) 0 DOG KENNEL 0 DAIRY <br /> SSS HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑ WASTEWATER TREATMENT PLANT <br /> '(�TIERED PERMITTED FACILITY 0 MOTELIHOTEL 0 PUMPER TRUCKIYARD/CHEM TOILETS <br /> ❑TATTOOIBODY PIERCING 0 POOL/SPA 0 LAND USE APPLICATION SITES <br /> 0 MEDICAL WASTE FACILITY 0 OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR RE%siLN - 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$105.00 deposit prior to review. <br /> EHD USE ONLY <br /> ***If you peed further assistance please contact Diane Martinez @ (209)468-3425 directly. Thank You*** <br /> I_ZW i I C4406f Q141 RqJ UAVaji co 91 P5 A h <br /> a CC b. goo . VI-0d; 1 <br />