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WAIt:rcrl-civtU EHD LOG NUMBER mc) (� V j�(�, SAN JOAQUIN COUNTY !J llkC L LD ENVI--,,JNMENTAL HEALTH DEPARTMEN f 600 East Main St. Stockton, CA 95202-2708 DEC U 7 2009 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: Www.sjgov.or ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION f E ..�,-,R�„;n am liVI11iVLIIVIVLl7 I�Z✓I G(� APPLICANT: I l A� `, 11t,��c BUSINESS/AGENCY: 0/ C'�,ed ADDRESS: X31 Sj �c CITY/STATE/ZIP: PHONE (1): IDI)b PHONE (2): i- (PGi - SS'-l/ FACSIMILE: ;,)9 ' 1-407- J)/6 TENTATIVE*APPOINTMENT DATE: Time: (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) ❑ CHECK BOX TO EXPEDITE REQU T-$115.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OF APPLICANT DATE Z Electronic Information: ❑ List ❑ Map-Description: FILE ADDRESS _ -17_ EHDONLY Street# Street Name City — -- ❑Unit 1 2. 3— --- ❑ Unit 2 \\�� 4 - ^\, El - Unit 3 Y 6. --- nit 4 7. 8. - 9 - _ ❑ Unit 5- 10. ❑ Unit 6 Specific Date Range of Information Requested: From to ENVIRONMENTAL HEALTH DEPARTMENT FILES UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYIVEHICLE OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE ❑UNDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL ❑HAZARDOUS WASTE GENERATOR El DAIRY ❑CHICKEN RANCH [–I WASTEWATER TREATMENT PLANT ❑TIERED PERMITTED FACILITY ❑MOTEL/HOTEL ❑PUMPER TRUCKNARDICHEMICAL TOILETS ❑TATTOOIBODY PIERCING ❑POOL/SPA El LAND USE APPLICATION SITES ❑ MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) 1. _List up to ten addresses in the space above. Select the type(s)of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the address indicated above Address ranges will not be accepted-for additional assistance with file addresses, contact the EHD. Applications received after 3:00 pm will be processed the next business day. 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a$115.00 deposit prior to review. EHD USE ONLY ***If you need further assistance Please contact Diane Martinez direct) @ (209)468-3425. Thank You*** can na_nc an��nno