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DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY �..r <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-2708 Soo <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sigov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: `✓' 1 / 1i G' P1-C� -j BUSINESS/AGENCY: ezeIiI <br /> ADDRESS: :�'�'C1 rl! ..:CITI fST E/ZIP <br /> PHONE(1): / 5/ SZf 1- t�J L%C' PHONE(2)r"�� � � ! 7 C l 7- FACSIMILE: (�l Z. )s-1-11 —C <br /> TENTATIVE*APPOINTMENT DATE: _. .__......._..... Time: <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> I CHECK BOX TO EXPEDITE REQU, T-5105.00 FEE( R CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT , DATE _ /G lZ G�' <br /> �~ <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# /1 Street Name Ciity ❑ Unit 1 <br /> 2. ❑ Unit 2 <br /> 3. oe <br /> � <br /> 4 Unit 3 <br /> 5. <br /> Unit 4 <br /> 6. <br /> 7. <br /> ❑ Unit 5 <br /> 8. <br /> 9. -`` ❑ Unit 6 <br /> 10. <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY/VEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑WASTE TIRE <br /> *1NDERGROUND TANK(MONITORINGIREMOVAL) 0 DOG KENNEL 13 DAIRY <br /> ,4' `IAZARDOUS WASTE GENERATOR 11CHICKEN RANCH 13 WASTEWATER TREATMENT PLANT <br /> , <br /> �I IERED PERMITTED FACILITY El MOTEL/HOTEL 0 PUMPER TRUCK/YARD/CHEM TOILETS <br /> i❑TATTOO/BODY PIERCING POOL/SPA ❑ LAND USE APPLICATION SITES <br /> 13 MEDICAL WASTE FACILITY ❑ 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 uv 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 for a 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$105.00 deposit prior to review. <br /> EHD USE ONLY <br /> ***If you need further assistance please contact Diane Martinez @ (209}468-3425 directly. Thank You*** <br /> FHn AR1 <br />