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SAN J OAQUIN COUNTY <br /> EW. )NMENTAL HEALTH DEPARTM. 1T <br /> 304 East Weber Avenue, 3'Floor, Stockton, CA 95102-2708 <br /> Telephone: (209)468=3420 Fax: (209)464=0138 145 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT; T. BUSINESSIAGENCY: <br /> ADDRESS: D ( `p <br /> PHONE(1}: �_ JGf— 7 3j0 PHONE(2):r21r19Q VS--��]a <br /> _ �a,_„FACSiMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-`Tentatfve only-must be confirmed) <br /> 13 CHECK BOX TO EXPEDITE REQUEST '$93.00 FEE(CASH OR CHECK ONLY)-.REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT <br /> DATE <br /> UNIT DISTRIBUTION PLICA <br /> Unit 1 ❑ Unit 2 On Unit 3 . ❑ Unit 4 ❑ Unit 5 ❑ Unit 6 ❑ Other(electronic/lists/maps) <br /> FILE ADDRESS <br /> Street# Street Name City EHD USE ONLY <br /> 1- ( � <br /> 2.. <br /> 3. <br /> L4. EMW <br /> a r . <br /> Specific Date Range of Information Requested:Fromto <br />�— NVIRONMENTA1—HEALTH DEPARTMENT FILES <br /> LUNDERGROUND <br /> OUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACIU YNEHICLE k <br /> LEANUP SITE(NON-LOP) v ❑FOOD FACILITY ❑WASTE TIRE <br /> TANK(MONCTORING/REMOVAL) M DOG KENNEL ❑DAIRY <br /> Us WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ERMITTED FACILITY ❑MOTELIHOTEL ❑PUMPER TRUCK/YARDICHEM TOILETS I <br /> ❑TATTOO/BODY PIERCING ❑POOL ISPA ❑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 AMd5;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 N <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 fora 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 /> � r <br /> -; QA <br /> EHD 48-M <br /> 1!14105 <br /> • �C <br />