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r <br /> DATE�JECEIVED EHD LOG NUMBER <br /> SAN aIOAQUIN COUNTY <br /> ( ENVIRONMENTAL HEALTH DEPARTMENT <br /> 11� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 O� <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd l J <br /> v <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: r I/YL2S BUSINESS/AGENCY: /71G <br /> ADDRESS: CITY/STATE/ZIP: <br /> PHONE(1): 416 PHONE 2): FACSIMILE: <br /> TENTATIVE'APPOINTMENT DATE: /Q / i; 1 Time: GY S <br /> (Please allow 10 business days from date alfplication submittal--Tenta . e ly-must be confirmed) <br /> ❑CHECK BOX TO EXPEDITE REQUT-$125FEES CHE ONLY)-REQUEST PROCESSED IN 3nBUSINEjSS DAYS <br /> SIGNATURE OF APPLICA �� �ylp/J DATE —41 //�- <br /> NT <br /> Electronic Information: ❑ Lis Map-Description: <br /> FILE ADDRESS EHD Use ONLY <br /> Street# Street Name City 014itl, <br /> 1. O r 5 Gf , 4 MM I , (t`( NIM /y <br /> ❑Unit <br /> 3. <br /> k <br /> 4. <br /> r r Unita <br /> 6• E] t4 <br /> a. <br /> ❑Unit 5 <br /> s. <br /> 10. ❑Unit 6 <br /> Specific Date Range of Information Requested: From to . <br /> .ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ,UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILI N HIC <br /> O❑0 ER CLEANUP SITE(NON-LOP) ElFOOD FACILITY ❑WASTE TIRE �.. j` nP / 61J1 3_ . <br /> ERGROUND TANK(MONITORINGIREMOVALV\ ❑DOG KENNEL ❑DAIRY F^.' ((JJ ` l.� <br /> F1 HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANr_e ' 1 <br /> ❑TIERED PERMITTED FACILITY ❑MOTELIHOTEL ❑PUMPER TRUCKMARDICHEMICAL TOILETS <br /> ❑TATTOOIBODY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑COMPLAINT 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 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:OD 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 fora 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 he reorganized by EHD staff at the expense of the applicant. <br /> Futu''reII file reviews by the same applicant may require a$125 deposit prior to review. <br /> Y ' :/ flj e. NL rl. <br /> - weatu <br /> s <br /> N pdq\ke W✓Gi,A005. kA-S fPj� <br />