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.......... � • EHD LOG NUMBER <br /> DATE R(EECEIVE(D� • SAN JOAQUIN COUNTY <br /> �j ECEWW ENVIRONMENTAL HEALTH DEPARTMENT \ r <br /> ZU�p 600 East Main St. Stockton, CA 95202-2708 <br /> JUN 0.2 1`elephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> ENVIROKIENT HEALTH PUBLIC RECORDS RELEASE APPLICATION�� <br /> APPLICANT: rh I1 lZ /��M BUSINESSIAGENCY: A(((/rw pcl <br /> ADDRESS: 3 4 /`I /��d ��f�Uc l� CITYISTATEIZIP: SV<0Y <br /> PHONE (1): `12 L^ 25" PHONE (2): �1 9 Z- Z g� GG 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 REQUEST-$11. 5.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> blZ �Q <br /> SIGNATURE OF APPLICANT 1//'„IVAI.� DATE <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑ Unit 1 <br /> 2. aq AUy 612 Sh ❑Unit2 <br /> 3. P/U <br /> 4. it 3 <br /> 5. '" <br /> 44- <br /> 6. <br /> 7. <br /> 8 ❑Unit 5 <br /> 9. <br /> 10. ❑Unit <br /> Specific Date Range of Information Requested: From all to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑DOG KENNEL ❑DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> TATTOOIBODY PIERCING ❑POOLISPA ❑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 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 20119)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$115.00 deposit prior to review. <br /> EHD USE ONLY <br /> ***If you need further assistance please contact Diane Martinez directly Cw (209)468-3425. Thank You*** <br /> FNfI dR.M1c <br />