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Paul Humphr—, REA, CAC F17,9-226-3408 P. <br />DATER'' �-- <br />:.. SAN JOAQUfN COUNTY EHD LOG NUMBER <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />� 600 East Main St. Stockton, CA 95202-3029 (� <br />Tele p me, (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />®WTA� ALL. <br />� t 61, <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: L� �L:'Y'y° BUSINESSIAGENCY: <br />ADDRESS; CITYISTATEIZIP. �t : 3737 <br />PHONE (1): 5 tf PHONE (2): FACSIMILE: Z 2% — d� <br />TENTATIVE' APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of a PPlicaticr submittal -Tentative only -must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST - $125 FEE (CASH OR CHECK ONLY) - RECUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE <br />Electronic Information: ❑ List ❑ Map — Description: <br />r j <br />Street k _ <br />FILE AODRiESS _ _ <br />Street Name City <br />-- --- <br />EHD USE ONLY <br />❑ Unit 1 <br />❑Unit 2 <br />® UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />_ <br />f- <br />© OTHER CLEANUP SITE (NON -LOP) <br />- <br />3. <br />UNDERGROUIDTANK (MONITORING/REMOVAL) <br />❑ DOG KENNEL <br />— -- <br />4. <br />- <br />- <br />5. <br />,Q TIERED PERMITTED FACILITY <br />❑ Unit 4- <br />6. <br />❑ TATTOOIBODY PIERCING <br />❑ POOLISPA <br />7. <br />❑ MEDICAL WASTE FACILITY <br />❑ COMPLAINT RECORDS <br />' - 3'I o El Unit 5 <br />t3' <br />9. <br />aA &Aj <br />U u -e' Unit 6 <br />10. <br />Specific Date Range of Jnformatlon Requested: From <br />r j <br />% <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />® UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />❑ SOLID WASTE FACILITYNEHICLE <br />© OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />❑ WASTE TIRE <br />UNDERGROUIDTANK (MONITORING/REMOVAL) <br />❑ DOG KENNEL <br />❑ DAIRY <br />HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ WASTEWATER TREATMENT PLANT <br />,Q TIERED PERMITTED FACILITY <br />❑ MOTELIHOTEL <br />❑ PUMPER TRUCKIYARDICHEMICAL TOILETS <br />❑ TATTOOIBODY PIERCING <br />❑ POOLISPA <br />❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY <br />❑ COMPLAINT RECORDS <br />❑ 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 fora 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 $125 deposit prior to review. <br />1►-�' - � ifs ��- f� <br />fid- <br />i <br />