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DA I Tk�v(_;DEIVED <br /> EHD LOG NUMBER <br /> ENVIRSAN .1OAQUIN COUNTY <br /> ONMENTAL HEALTH DEPARTMor <br /> NOV 15 Z011 600 East Main St. Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ('2<0 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESS/AGENCY: <br /> ADDRESS: 225S� �lwke� 2,� CITY/STATE/ZIP: <br /> PHONE (1): PHONE (2): FACSIMILE: 6'25 <br /> TENTATIVE`APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-"Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List ❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City - ❑ Unit 1 <br /> Gr <br /> 2. ❑ Unit 2 <br /> --- L <br /> 3. <br /> --- -- - <br /> 4. o-E] Unit 3 <br /> - - - -- - - -- - - — — - --- --- <br /> 5. .2 r, LAS <br /> 6. �;�� Q: �0'k-1 Q� nit 4 <br /> 7. <br /> 8. ❑ Unit 5 <br /> 9. <br /> 10. 1 1 1 1 ❑ Unit <br /> Specific Date Range of Information Requested: From /CIR9 to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL ❑DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑MOTEL/HOTEL ❑PUMPER TRUCKNARDICHEMICAL TOILETS <br /> TATTOO/BODY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑COMPLAINT 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 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 file type MUST be selected. Fax to(209)464-0138 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 EHD staff may not be immediately available for review. A new application may be <br /> 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 m require a $1 posit prior to review. <br /> A,Er oar <br /> END 48-06 811111 <br />