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LN'11 C IV CU ---- <br /> SAN JOAQUIN COUNTY <br /> HOMED - ElNWN—ONKI NTAL HEALTH DEPARTML+L[J.304 East Weber Avenue, 3"Floor, Stockton, CA 95202-2708 <br /> 5E7g05Telephone: (209)468-3420 Fax:(209)464-013&Web:www.sjgov.orglehd go <br /> i j fi1;�,E s N 0,HPUBLIC RECORDS RELEASE APPLICATION <br /> APPLlCAtTT� ,�:. , J <br /> # �� BU5INESSlAGENCY: <br /> ADDRESS: <br /> PHONE(1): f1) �/7 -IPHONE(2): r. �� FACSIMILE <br /> TENTATIVE'APPOtmuw DATE: Time; <br /> (Please allow 10 business days from date of application submittal-'Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE(CASH OR CHECKONLY)—REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> 1GNATURE OF APPLICANT —� �- '� ~� DATE <br /> UNIT DISTRIBUTION ❑ Unit 1 ❑ Unit 2 IIPPUM Unif 4 Unit 6 E7 Unit 6 ❑ Other(electronictlistslmaps) <br /> FILE ADDRESS EHD SE ONLY <br /> Street Il Street Name Ci <br /> 2. �� <br /> �3. <br /> 4. �d <br /> 7. <br /> 8. <br /> 9. <br /> 10. <br /> Specific Date Range of Information Requested:From to <br /> ENVIRONMENTAL HEALTH DEF ARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SIE(LOP) ' 0 HouslNG ABATEMENT ❑Sam WASTE FACUMMEHICLE <br /> OTHER CLEANUP SITE(NoN-LOP) 0 rOOD FACLLSTY ❑WASTE TIRE <br /> UNDERGROUND TANK(MoNLTOR NoMEmovAL) ❑DOG KENNEL. 11 DAIRY <br /> �TIERED <br /> HAZARDOUS WASTE GENERATOR 13CIjICKEN RANCH 13WASTEwAmR TREATMENT PL ANT <br /> PERMITTEDFAcLay [3M6TL:LMoT cL L7 PumPER TRLICKIYARDICHEM TOILETS <br /> TATTOOIBODY PIERCING CI POOLISPA 13LAND USE APPLM.AnoN SaEs <br /> ❑MEDICAL.WASTE FACILITY ❑OTHER(PLEASE SE SPE <br /> WELL.AND SEPTIC PERMIT REcopm ARE AYA&ABLE FOR REVIEW- M AY-FRIDAY 8:00 AIA-6:00PU - 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)4G4-0138 or mail to the address <br /> Indicated above. Address ranges will not be accepted--for idditional assistance with file addresses,contact <br /> the EHD.Applications received after 3:00 pm will be process .d the next business day. <br /> 2. The EHD will notify the applicant if any EHD files exist. Anappointment 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 accord ngly. <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 depositprior to review. <br /> n <br /> v. <br /> F11 -02_00c <br /> " 11f2S(04 - <br />