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DATE RF IYED - �-• EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY ��yy O PY <br /> NVIRONMENTAL HEALTH DEPARTIGf€fV� <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> MAR U 5Tp�fphone (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> ti <br /> APPLICANT: G ZX/4` SINESS/AGENCY: <br /> ADDRESS: L jti � CITY/STATE/ZIP: <br /> PHONE (1): %7 7 PHONE (2): 2,2/ ~Z17S FACSIMILE: <br /> TENTATIVE"APPOIN MENT DATE: Time: <br /> (Please allow 10 b siness days from date of application submittal-"Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDIT REQUEST=1175,F ASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUS NESS DAYS <br /> SIGNATURE OF APPLICAN ^---� DATE 03 `T 12 <br /> Electronic Information: ❑ Lilst ❑ Map—Description: <br /> FI E ADDRESS EHD USE ONLY <br /> Street# treet Name City ❑ Unit 1 <br /> ID - SyZr �� <br /> 2. <br /> ❑ Unit 2 <br /> 3. <br /> 4. <br /> ❑ Unit 3 <br /> 5. <br /> 6. ❑ Unit 4 <br /> 7. <br /> 8. ❑Unit 5 <br /> 9. <br /> 10. ❑ Unit 6 <br /> Specific Date Range of Information Re uested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑UNDERGROUND TANK(UST)CLEANUP ITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYNEHICLE <br /> ❑,OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORING/RE OVAL) ❑DOG KENNEL ❑DAIRY <br /> AZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTEL/HOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TATTOOIBODY PIERCING ❑POOUSPA ❑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 pace above. Select the type(s)of files from the list above by checking the appropriate <br /> box(es). At least one file type UST be selected. Fax to(209)464-0138 or mail to the address indicated above. Address <br /> ranges will not be accepted-fo additional assistance with file addresses,contact the EHD. Applications received after <br /> 3:00 pm will be processed then xt business day. <br /> 2. The EHD will notify the applican 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 according y. <br /> 3. A file that is actively being work d on by EHD staff may not be immediately available for review. li <br /> submitted when the file is avail ble. hd <br /> 4. An file not returned in the sam condition as released will be reorganized b EHD staff at the ex f th a <br /> Y 9 Y exp <br /> Mf <br /> file reviews by the same pplicant may require a$125 deposit prior to review. <br /> l Of ` EHD USE ONLY <br /> 01 ­7 / <br /> EHD 8-06 8/1/11 <br />