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DATE RECEIVED ^ t:MU LU'o NUMUCK <br /> SAN JOAQUIN COUNTY <br /> n E' <br /> S <br /> JENVONMENTAL HEALTH DEPARTIINT <br /> 304 East Weber Avenue, 3d Floor, Stockton, CA 95202-2708 <br /> APR 9 w <br /> a 2005 Telephone: (209)468-3420 Fax: (209)464-0138 Web:ww .sjgov.orglehd <br /> pW�jjFF� ,FENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLROANIlT' �p BUSINESS/AGENCY: <br /> ADDRESS: 1KT7 /iP!/ <br /> PHONE(1� ) 1932.— !:P 7/Z PHONE(2):(,;Z-� FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUES -$93.00 FE (C OR CHECK ONLY)—REQUEST PROCESSED IN 3 BUSINESS DAYS fly <br /> SIGNATURE OF APPLICANT DATETF <br /> UNIT DISTRIBUTION A Unit 1 ❑ Unit'i Unit 3 Unit 4 Unit 5 ❑ Unit 6 El Other(electronlcAistslmaps) <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City <br /> 1. <br /> 2. 3 7 <br /> 3. <br /> 4. <br /> 5. <br /> 6. <br /> 7. <br /> 8. <br /> 9. <br /> 10. <br /> Specific Date Range of Information Requested: From C 1i I AO ZO( 7 9 to 0 L4 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> )M UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT El SOLID WASTE FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) 13 FOOD FACILITY O WASTE TIRE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL O DAIRY <br /> ❑HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH 13 WASTEWATER TREATMENT PLANT <br /> 10 TIERED PERMITTED FACILITY 0 MOTEL/HOTEL 13 PUMPER TRUCK/YARD/CHEM TOILETS <br /> 0 TATTOOIBODY PIERCING 0 POOLISPA ❑LAID USE APPLICATION SITES <br /> 13 MEDK:AL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW- MONDAY-FRIDAY 8:00 AMS: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 /> EHD 48-02-M <br /> 11123!04 <br />