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DATE RECEIVED �, EHD LOG NUMBER <br /> SAN .IOAQUIN COUNTY <br /> s��,�;,,�� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 n <br /> JUN I"� T3 <br /> p) phone:(209)468=3420 FaX:(209)464=0138"Web: wvtw.$)gov.org/ehd r <br /> ENVR. NT. s ;—v:,ALT)PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICAN- BUSINESSIAGENCY:/ ,; �pPe482,,� <br /> ADDRESS: 3 ,i 2t�ils CITYlSTATE/ZIPL / Ip��� <br /> PHONE (1): JO- 9g3 PHONE (2): FACSIMILE: <br /> TENTATIVE`APPOINTMENTDATE: Time: <br /> (Please allow 10 business days from date pp w n submittal-"Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE EST-$I F (CASH OR qHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLIC T DATE <br /> Electronic information: ❑ List❑ M —Descriptio . <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name city Unit1 <br /> L7 <br /> 2. <br /> Unit 2 <br /> 4. <br /> nit 3 <br /> 6. <br /> 7. (7041, <br /> 8. <br /> 'Unit 5 <br /> 9. <br /> 10. <br /> nit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY SOLID WASTE FACIUTyNEHICLE <br /> jig OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT WASTE TIRE <br /> FUNDERGROUND TANK TMONITORINGIREMOVAL) MFOODFACILITY ❑DAIRY <br /> u ABOVEGROUND TANK CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WAsTElHAZARDOUs MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> TIERED PERMITTED FACILITY POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOOIBODY PIERCING 9COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILA LE 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 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$125 deposit prior to review_ ­BOXED AREA-EHD USE ONLY`*' <br /> ❑ Records provided by Staff-PPR Complete. staff Name: <br /> EHD 4&D6 <br /> 9/4112 <br />