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D QE} S EHD LOG NUMBER <br /> AN JOAQUIN' COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Aha 0 5 2007 304 East Weber Avenue, 3�d Floor, Stockton; CA 95202-2708 <br /> EN1flROE MI IST ALT q7elephone: (209)469-3420 Fag: (209)454-0138 Web: www.sigov.org/chd <br /> PERMIT/SERVICES <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: . VL ��. _. S"1-(Z yj A BUSINESSIAGENCY: <br /> ADDRESS: 1 '., 3 3 <br /> PHONE(1):�5 acs\i.� t 2` `� 1 —PHONE(2): E FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: +s Time: <br />` (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> CHECK BOX TO EXPEDITE REQUEST-$95.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE - C o- <br /> Electronic Information: ❑ List❑ Map-Description: <br /> FILE ADDRESS. EHD USE ONLY i <br /> Street# Street Name City i ❑ Unit 1 <br /> 1. 11 t;O S • MMO- STKI i~T 11II09L (f* '` 4 <br /> 2. ❑ Unit 2 <br /> 3. if <br /> 4. -90OUnit 3 <br /> 6. - <br /> 7. <br /> .7. <br /> Uhit <br /> 8. <br /> Dig 5 <br /> f <br /> f <br /> E <br /> ❑ uni10. t s <br /> Specific Date Range of Information Roquested:From y. to . <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> i UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILnl VEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILn7Y ©WASTE=TIRE ti <br /> A UNDERGROU"b TANK(MONITORINGIREMOYAL) ❑DOG KENNEL ©DAIRY <br /> HAZARDOUS WASTE GENERATOR 13CHICKEN RANCH F D WASTEWATERTREATMENT PLANT <br /> �j TIERED PERMOTED'FACILITY ❑ <br /> L'� MOIELMOTEL <br /> 13 PUMPER TRUCKIYARDICHEM TOILETS m <br /> TATTOoMooY PIERCING 0 POOUSPA ❑LAND USE APPLICATION StTfS. <br /> MEOICIU.WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> i WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REv1Ew MONDAY-FRIDAY 5:00 AM 5:OOPM - EXCLUDING HOLIDAYS. <br /> 4 1. List up to ten addresses in the space above. Select the typo(s)of Files from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(2091464-0138,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 flue:business days for review. Appointments <br /> 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 application may be <br /> L 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 applicant. <br /> Future file reviews by the same applicant may require a$95.00 deposit prior to roviow., <br /> EHD USE ONLY <br /> t ," <br />