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SAN JO <br /> I V� AQUIN COUNTY <br /> EN_ -zONMENTAL HEALTH DEPARTP,��T <br /> 31 2011 r, 0 East Main St. Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sigov.org/ehd <br /> ENVIRONMENTAL HEAi� <br /> ENVIRo PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: Q\_ �,, 4, BUSINESS/AGENCY: 1� <br /> ADDRESS: {�(� 3 7� aZ ± <br /> ' <<� CITY/STATE/ZIP: c, <br /> DZ1�Tar� �1� 7�7 h j <br /> PHONE (1): a L?j � a- 4`1 C)b PHONE (2): 0, y-t D5, FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: 5 <br /> (Please allow 10 business days from date of application submittal-*Tentafive only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST 122 FEE(CASH.QR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE__q3j It <br /> Electronic Information: ❑ List❑ Map—Description: <br /> --FILE ADDRESS EHD USE ONLY <br /> 7Street# - - Street Name City <br /> Unit 1 <br /> 2. <br /> 3. - - -- --- --— -- --- -- - - — Unit 2 <br /> 4. <br /> - - — -- - .ff Unit 3 <br /> 5. — --- - --- - --- ---- - <br /> 6. <br /> P <br /> 7. <br /> 8. <br /> . - _-� -- --- ----_ — .— --- — - nit 5 <br /> 9. <br /> 10. <br /> * nit <br /> Specific Date Range of Information Requested: From I-CkAS`G k o to N <br /> ENVIRONMEN AL HEALTH DEP RTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) HOUSING ABATEMENT ❑SOLID WASTE FACILITYNEHIGLE <br /> OTHER CLEANUP SITE(NON-LOP) FOOD FACILITY ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) DOG KENNEL ❑DAIRY <br /> HAZARDOUS WASTE GENERATOR N CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑MOTEUHOTEL <br /> ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> TATTOO/BODY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> MEDICAL WASTE FACILITY ❑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 may require a$122 deposit prior to review. <br /> EHD USE ONLY <br /> EHD 4M6 <br /> 07129110 <br />