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n,\- <br /> /N 05/03/2005 15: 13 FAX ff1J 001 <br /> EHD LOG NUMBER <br /> ' DATI RECEIVED SAN JOAQUIN COUNTY <br /> RECE vM ED ENVIRONMENTAL HEALTH DEPARTMENT 17Kol '304 East Weber Avenue,3rd Floor, Stockton, CA 95202-2708 <br /> klAy 0 1005Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> EN11VYi��RppO�pNp�MrENT HEALTH PUBLIC RECORDS RELEASE APPLICATIO�N� <br /> APPLICCAANT: wit , - BUSINESSIAGE <1NCY: &-w FY/VIL/1 VY7P <br /> ADDRESS: L '1 <br /> PHS,NE(1):G 75-7�R` - F,3S'-I PHONE(2): FACSIMILE: <br /> TENTATIVE'APPOINTMENT DATE: Tim; <br /> (Please allow 10 business days from date of application submittal-•Tentative only-must be confirmed) <br /> CHECK BOX TO EXPEDITE REQUEST.$93.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT lr`��� lr DATE .5 3'05 <br /> �UNITDISTRIBUTION 1 ❑ Unit 1 ❑Unit 2 ❑Unit 3 ❑Unit4 OUna6 CI Unite 0 Other(electronic/listslmaps) 12 <br /> � FILE ADDRESS L9 USE O Y 1 <br /> yStmet# Street Name City <br /> FN�USr 1 <br /> US 2 _ <br /> 3. 00 _ a <br /> 4. <br /> 6. <br /> 7 -- r <br /> _8. <br /> 1 D. !v <br /> fir\ to �— <br /> Specific Date Range of Information Requested:From P <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> r� UNDERGROUND TANK(UST)CLEANUP SITE(LOP) In HOUSING ABATEMENT r7l SOLID WASTE FACILITYNEHICLE <br /> EI!,STHER CLEANUP SITE(NON-LOP) 13FOOD FACILITY ❑WASTE TIRE <br /> U1 I)NDERGROUND TANK(MONITORINGIREMOVAL) ❑DOC KENNEL M DAIRY <br /> *HAzARDDus WASTE GENERATOR ❑CHICKEN RANCH Tff WASTEWATER TREATMENT PLANT <br /> ❑(IERED PERMI,TED FACILITY ❑MOTELIHOTEL 0 PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑'IATTDOIBOD'f PIERCING O POOUSPA M LAND USE APPLICATION SITES <br /> ❑MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR RENEW - MONDAY-FRIDAY 6:00 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 <br /> appropriate box(es). At least one file type MUST be selected. Fax to(209)484-0138 or mall to the address <br /> indicated above. Address ranges will not be accepted—for additional assistance with file addresses,contact <br /> the EHD.Applications received after 3:00 pm will be processed the next business day. p <br /> 2 The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> approximately ten(10)days after receipt of application. The files will be held for a maximum of five business <br /> days for review. Appointments 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 I <br /> application may be 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 <br /> applicant. Future file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> EI Ire 18 WAN <br /> 111.de6 <br />