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AP03.13. 2005 9.21AM ADVANCED GEO No. 0121 EHDP' 1NUMBER <br /> DATE SAN JOAQUIN COUNTY <br /> " ,1 ENVIRONMENTAL HEALTH DEPARTMEr <br /> E I's <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> A IDR 13 2005 Telephone: (209)468-3420 Fax-, (209)464-0138 Web:www.Sjgo�,org/ehd <br /> 1101 <br /> ENV! ONKlENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> M- 1171 APPLICANT; .3 <br /> BUSINESSIAGENCY: <br /> ADDRESS: <br /> PHONE(1): Z.l (,f/i77 � PHONE(2): FACSIMILE: <br /> TENTATIVE"APPOINTMENT DATE: Time. b <br /> (Please allow 10 business days from date of application submittal-"T'enfaLve only-must be confined) <br /> HECK BOX TO EXPEDITE REQUE 3. <br /> OR CHECK ONLY)-REQUEST PROCESSED IN S B SINES DAYS .1/ <br /> SIGNATURE OF APPLICANT DATE <br /> UNIT DISTRIBUTION 13 Unit 111 nit 2 jAnit _111111111114gI unit 5 0 Units 0 other(elewo"Iclllswmaps) <br /> FILE ADDRESS EHD USE ONLY <br /> Street Street Name City <br /> - <br /> 2. <br /> 3. >� <br /> 4. U Vf� <br /> 5. <br /> 6. �D <br /> 7. <br /> J. <br /> 9. <br /> 10. <br /> specific Date Range of Information Requested:From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 HOUSING ABATEMENT ❑SoUD WASTE FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) E3 FooD FACILITY a WASTE TIRE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑DOG KENNEL 0 DAIRY <br /> HAZARDOUS WASTE GENERATOR O CHICKEN RANCH 0MASTEwATER TREATMENT PLANT <br /> O TIERED PERMITTED FACILITY 0 MOTEUHOTEL 0 PUMPER TRUCKIYAi TOILETS <br /> 0 TATTOOIBODY PIERCING 0 POO1ISPA j$'LANo USE APPLICATION <br /> SSITES <br /> 0 MEDICAL WASTE FACILITY 0 OTHER(PLEASE SPECIFY) <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 EHD,Applications received after 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 <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 /> - <br /> END 4"2406 <br /> 1/14M <br />