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Ho—) <br /> SAN JOAQUIN COUNTY �! tHu LUG(yumut <br /> MC E L V E DD ENVIRONMENTAL HEALTH AEPAR'Tm-ENT <br /> 304 East Weber Avenue, 3rd ton, CA 95202-2708 <br /> MAR 2005 Telephone; (209)468-3420 Fax (209)464-013 Web: www.sjgov.org/ehd <br /> ENVIRONMENT HEALTH pIUBLIC CORDS RELLASE APPLICATION <br /> APPLICANT: <br /> BUSINESSIAGENCY: <br /> ADDRESS: <br /> PHONE(1);c�� �"' � PHONE(2): enp <br /> TENTATIVE'APPOINTMENT DATE: <br /> (PleaSe allow 10 business day$from ddte of appilcation submittal-"TenfaUve only-must co finned) <br /> 171 CHECK BOX TO EXPEDITE REQUEST--$93.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT „�=�"`_`{--� �� <br /> DATE y <br /> UNIT DISTRIBUTION ❑ Unit 1 ❑ <br /> Unit 2 C3 Unit 3 nit 4 b Unit S Cl Unit 6 E3 Mar(etectroniC/lists/maps) <br /> FILE ADDRESS <br /> Street# Street NameEHD USE ONLY <br /> Ctty <br /> 4. b yj <br /> 6. fil�Lr'l�Lsl,�i� Z ell •f <br /> . <br /> 10, <br /> AY,' , <br /> Specific Date Range of Information Requested;From .. <br /> to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 0 UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYIVEHICLE <br /> O OTHER CLEANUP SITE(NON-LOP) <br /> UNDERGROUND TANK(MONITORiNG/i�MOVAL) 0 Dom)FAcIuTM ❑WASTE TIRE <br /> ❑HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH O DAIRY <br /> 171 TIERED PERMITTED FACILITY MOTEL/HOTEL WASTEWATER TREATMENT PLANT <br /> ❑TATTOO/BODY PIERCING ❑PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ME=DICAL WASTE FACILITY ❑POOL/SPA ❑LAhND`USE APPLICATION SITES <br /> . <OTHRR(PLEASE SPECIFY)1:1 � �0 f <br /> WELL.AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW- MONDAY-FRIDAY 8:00 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 209 464-0138 or mail to the address <br /> indicated above. Address ranges will not be accepted-for additional assistance with file addresses,contact <br /> the EHO.Applications received after 3:00 pm will be processed the next business daffy. <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 <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 /> EHO 43-02.006 <br /> 7 7/y71p4 <br />