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EHD LOG NUMBER <br /> T DATE RECEIVED SAN JOAQUIN COUNTY <br /> i <br /> 40 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> elephone:"(209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org1ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> r r� J q�J BUSINESSIAGENCY. 4 <br /> APPLICANT. if 1� r"� i� � -4f�,,�t' �� kk <br /> ADDRESS, <br /> Cep �I cid LG l l?(LCiT�(T!5�EIZIP: i�G�(.C� <br /> 0 ` `S -- J 0 9 PHONE(2): nit?-- �'�— j FACSIMILE: <br /> PHONE(1): �h Time: <br /> rEnrTATNE*APPOINTMENT DATE: <br /> (Piease allow 1 d business days from date of application submittal-*?enfafive only-must be confirmed) <br /> ❑CHECK BOX TO EXPEDITE REQUEST-S125 FEE(CASH OR CHECK ONLY)-REQUEST pR<)GESSSTI3 IN BUSINESS DAYS <br /> D � <br /> SIGNATURE OF APPLICANTT = <br /> Electronic Information: ❑ List❑Map—Description: u �a <br /> FILE ADDRESS EHa <br /> - <br /> Street# Street Name Cit r �7'Unit 1 <br /> 1. _ _. ► �� I ljnit2 <br /> 3. ,.—�, res _ ! }� � �• <br /> 4. e _ _ ©Unit 3 <br /> 6. V ❑Unit 4 <br /> 7. <br /> ❑Unit 5 <br /> 9. <br /> 14. ❑Unit <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑T SOLID WASTE FACILITYNEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑MOUSING ABATEMENT ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONIT ORINGIREMWAL) ❑FOOD FACILITY" ❑DAIRY <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCHI[JOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> L]HAZARDOUS WASTEIHAZARDOUS MATERIALS F1MOTEUHOTEI ❑PUMFERTRl7CKIYARDICHEM[CAL TOILETS" <br /> ❑TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOOMODY PIERCING ❑CiOMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW.- MONDAY-FRIDAY 8:40 AM-5:QOPM(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 fie type MUST be selected. Fax to 209464-0138 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 EHID staff may not be immediately available for review. A new application may be <br /> submitted when the file is available. <br /> 4. Any fife 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$125 deposit priorto review. ,BOXED AF?EA' 11�USE;ONLY <br /> ..x :a•;,Y '� ,. '.�y ""� �a,_ `. 'rte� �� : ,s l..r'. • 'prt�:;�� � <br /> ❑ Records provided by Staff-PPR.�Gorn 616.Staff[+lame: . � -- ":a`"" �.� - - <br /> 914112 <br /> EHd Is-06 <br />