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VU t WNUUK LAKIH ECH NO 5926 P 2 <br /> L2„CL , <br /> meati �Ei {Jepl ILU <br /> / • SAN JOAQUIN COT11V'1;X � EHD LOG NUMBER <br /> �' `'��� •_ i CSI I'� .F-NMONM <br /> IV`1'A.L$EAI.TH Dl;l'AiRTMENI' <br /> ENV1RU,1!biEti1 HEALTH 304 East Weber Avenue, 3”Floor, Stockton,CA 95202-2708 253s Telephone:(209)468.3420 Fax: 209 464-0138 Web:www.ajgov.org/ehd� <br /> PIIBL C RECORDS RELEASE APPLICATION <br /> *7 <br /> APPLICANT; N 1 <br /> ADOREss: ( Q�a ,\ SIN /AGENCY; (L <br /> VVTT// „ Lei !all r <br /> P � <br /> HONE(1):a �� 1P , <br /> PHONE(2): -3-09- 01- ovoz- W F' <br /> ACSIMILE: 4 / y� JA <br /> TENTATIVE APvomrMENTDAT,: d2 0� 13PPfl1 <br /> (Please allow t0 business days from d D 'cation submittal Trine: <br /> Tegtaf/vD only-must be confirmed) <br /> CHECK 13OX TO EXPEDITE RE T.$93.0 FEE( CHECK ONLY)-REQUEST PROCESSED INaU INESS DAYS <br /> SIGNATURE OF APPLIC T Ot° <br /> DATE <br /> UNIT bISTRISUTION ❑Unit 1 EJUnft2 ❑Unit <br /> Unha ❑UmitS O Units ❑ Other(Dleotronic/lists/maps) <br /> FILE ADDRESS <br /> Shcct# Street Name -+b EHD USE ONLY <br /> 1. tl <br /> 2. ( P f AW <br /> 3, p Lt <br /> 4. 1 Lk <br /> 6.7. <br /> �- 5 ,• f f,, <br /> 9• 10 iA Ac - <br /> 10. 20 <br /> Specffic Date Range of Information Requested:From <br /> to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SrM(LOP) ❑HOVSING ABATEMENT QTHER CLEANUP SITE(NON-Lop) <br /> ❑FOOD NG ABY 11 elUD WASTE FACjUiYNENICLE <br /> NDEROROUNDTANK(MONITORIRWREMOVAL) ❑FOG FACILr OWAMTIRE <br /> 1`1 A 0ous WASTE GEnERATOR p DOG Cl DAIRY <br /> TIEREO PERMaTED FACILrY KEN ITANCH ❑WASTEWATER TREATMENT PLANT <br /> 0 TATTOGISOOY PIERCING ❑MOTELIHOTFJ• PUMPER TRVGK/YARO/CNEM TOILETS <br /> MEDICAL WASTE FAaUTY POOU9PA )d LAND USE APPUCATION SITES <br /> OTHER(PLEASE SPE,,Y) <br /> WELLANDa diesEPTIC esinRECORDS ARE above.EFOR RENEW• MONDAY.FRl0AY 5:00 AM 5,00PM ExCLUDn+G H000AYs, <br /> 1. List up to ten addresses in the space above. <br /> appropriate Select the type($)of files from the list above by checking the <br /> Indicated aboOveVe. Addrr least one file type MUST be selected. Fax 4-(1 <br /> _ax to(209)46138 or mail to the address <br /> ),Address ranges will not m accepted—for addrhonal assistance with file addresses, contact <br /> the EHD.Applications received after 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 <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, Anew <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..$93.00 deposit prior to reyiew. <br /> EHD i&C2-0(16 <br /> lrvo$ <br />