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_ EI-ID LOG NUMBER <br /> DATE RECEIV,EG - SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> _--Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: wv}n-v.s}gov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> f7 <br /> � <br /> APPLICANT:_ BUSINESS/AGENCY: <br /> ! <br /> ADDRESS: aJ� 15()i7� j5 CITYISTATEIZIP: <br /> PHONE(1): %/� �f . ;20 PHONE(2): z�� /77,!:)?/FAC sIMILE: >/G 5 ` <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 REQUE�FEE S R CHECK ONLY)-REQUEST PROCESSED IN 3 BUESS DAYS <br /> SIGNATURE OF APPLICANT � ��� DATES_z2� ��— <br /> Electronic Information: ❑ List❑ Map–Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑ Unit 1 <br /> 2. �� e�—a -�lCll S f% 4d� ❑ Unit2 <br /> 4. E] Unit 3 <br /> 5. <br /> I- ❑ Unit <br /> 7. <br /> 8. <br /> ❑units <br /> 9. <br /> 10. ❑Unit 6 <br /> Specific Date!Range of information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT E]SOLID WASTE FACILITYNEHICLE <br /> 0 OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORiNGIREMOVAL) [:100(3 KENNEL ❑DAIRY <br /> Xj HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> 9TIEREDPERMITTED FACILITY 0 MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICALTOILETS <br /> Ll 1 ATTOOIBODY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑COMPLAINT RECORDS ❑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 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 prn will be processed the next business day. <br /> 2. The EHD,6 rill notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) <br /> days after receipt of application. "rhe files will be held for a maximurn of fire 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 /> si b-nitt-ad when the file rw available. <br /> a. Any file rot returned in the same condition as rLlessed t-.€II be reorganizecl by EHO staff at the e:-pense of the applicant., <br /> =:tx°ra fila revis\v S',Wle a;)plica:nt may reciUire a$125 deposit prior to raviaw, <br /> �—.�rr.li:..ar_f.iLY -- --- — <br />