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DATE RECEIVED SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT:''- v . S BUSINESSIAGGENCY: '. ",:"5-,�,."• <br /> ADDRESS: "� City/Staterzip C". Aa r\t <br /> C`� *)... - PHONE(2) 10 �a 4 '.Z 0.L~t FACSIMILE 1�" <br /> PHONE(1): 6_� <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> Q CHECK BOX TO EXPEDITE $105 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANTDATE x•- l <br /> Electronic Information: ❑List❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑ Unit 1 <br /> 2. ❑ Unit 2 <br /> 3. <br /> -- -—" — ❑ Unit3 <br /> 4. <br /> 6. ❑ Unit 4 <br /> 6. <br /> 7 — <br /> ❑ Unit 5 <br /> L19O. <br /> 171Unit 8 <br /> Specific Date Range of Information Requested:From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> O UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 HOUSING ABATEMENT ❑SOLID WASTE FACILITYIVEHICLE <br /> ,OTHER CLEANUP SITE(NON-LOP) O FOOD FACILITY 0 WASTE TIRE <br /> O UNDERGROUND TANK(MONITORINGIREMOVAL) M DOG KENNEL Q DAIRY <br /> 13 HAZARDOUS WASTE GENERATOR M CHICKEN RANCH 13 WASTEWATER TREATMENT PLANT <br /> 13 TIERED PERMITTED FACILITY M MOTEL/HOTEL 13 PUMPER TRUCKIYARDICHEM TOILETS <br /> CI TATTOO/BODY PIERCING O POOL/SPA E3 LAND USE APPLICATION SITES <br /> O MEDICAL WASTE FACILITY E3 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 flies 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 reorganfzed by END staff at the expense of the applicant. <br /> Future file reviews by the same applicant may require a$105 deposit prior to review. <br /> EHD USE ON Y _ <br /> � : ZP08 <br /> EHD 48-06 8/04/08 PUBLIC RECORDS RELEASE APP FORM <br />