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:;� • R�tiv.`.t2�tat-:tzi4�`:r'+!'ti'si� `�91 �fC'.;:�::�:•�.-,_ '.': '�t'si�l • -- -`;3�t+►�lCti;::t�,�:2?2v?:K�3:est,:Y�etisat=latia\ <S�t1.`�ti�. <br /> DATE RECEIVED SAN JOAQUIN GOU RL E C01" Y <br /> EHD LOG NUMBER <br /> ENVIRONMENTAL HEALTH DEPARTMENT a l 11 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESS/AGENCY: <br /> ADDRESS: c�� <br /> - � JC 2—Z-5- CITY/STATE/ZIP:-4�,c-t�--{Z,.-,,�� <br /> PHONE (1): PHONE (2): FACSIMILE: <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$12VFEE C H OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANTDATE /�` — <br /> Electronic Information: ❑ List❑ Map—Description: ✓ <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑ Unit 1 <br /> 2. <br /> ❑ Unit 2 <br /> 3. 4 <br /> ❑ Unit 3 <br /> 5. <br /> 6. t <br /> ❑ Unit 4 <br /> 7. <br /> 8. <br /> ❑ Unit 5- <br /> 9. <br /> 10. <br /> ❑ unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYNEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORING/REMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCHI DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ❑HAZARDOUS WASTE/HAZARDOUS MATERIALS MOTELIHOTEL ❑PUMPER TRUCK/YARD/CHEMICAL TOILETS <br /> ❑TIERED PERMITTED FACILITY L POOL/SPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOO/BODY PIERCING ❑COMPLAINTIRESPONSE 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 UD 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.Applications received after 3:00 pm will be processed the next business day. <br /> 2. For assistance in identifying the nature and content of EHD records,please contact EHD at the number noted above. <br /> 3. 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 /> 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$125 deposit prior to review. ***BOXED AREA-EHD USE ONLY*** <br /> 7 <br /> i <br /> 1040, b P, r S � <br /> Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 48-06 <br /> 4@8/1 <br /> Af— <br /> �10 <br />