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DATE RECEIVED EHD LOG NUMBER <br /> SAN .1OAQUIN COUNTY <br /> �tF)) ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ;( I 1N NTelephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.or <br /> 4�SOME <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLIQT' L: AY BUSINESS/AGENCY: 1 � <br /> ADDRESS:' X71 UY 11 lit if CitylStatelZiri_ r��/'>�/C !✓ <br /> PHONE(1 ��1 !. f f�"�. D ` PHONE(2'/ JT FACSIMILE: r <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-$105 FEE(CA H OR CHECK ONLY)-REQUEST PROCESSED IN BUSINIE S DAYS <br /> SIGNATURE OF APPLICANTa �r�]_ -_( = (�i� DATE / )y y <br /> Electronic Information: ❑ List❑ Map-Description: <br /> .. FILE ADDRESS .. ._.. ._ .... ...-_........._ . .. .__ .. . _ . .. . .. _ <br /> EHD USE ONLY <br /> Street Street Name city E] Unit 1 <br /> 2. ❑ Unit 2 <br /> 3. <br /> . . �- -4--- -- --- - - - - - ----- --- -- -- �Unit - / <br /> 5. <br /> Unit 4 <br /> 6. <br /> 7. <br /> ❑ Unit 5 <br /> 6. <br /> 9. <br /> ❑ Unit 6 <br /> 10. <br /> Specific Date Range of Information Requested: From to <br /> ,�� ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> '��dNDERGROUND TANK(UST)CLEANUP SITE(LOP) 13 HOUSING ABATEMENT ❑SOLID WASTE FACILITYCI <br /> �THER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY CIWASTE TIRE <br /> LiNDER0ROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL' ❑DAIRY - <br /> -E1rHA7ARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTELIHOTEL ❑PUMPER TRUCK/YARDtCHEM TOILETS <br /> ❑TATTOO/BODY PIERCING CI POOL/SPA (3 LAND USE APPLICATION SITES <br /> ❑MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW - MONDAY-FRIDAY 8:00 AM-5:00PM - EXCLUDING HOLIDAYS. <br /> 1. List up to ten addresses in the space above. Select the type(s)of files from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to 209 464-0138 or mail to the address indicated above. Address <br /> ranges will not be accepted-for additional assistance with file addresses,contact the EHD. Applications received after <br /> 3:00 pm will be processed the next business day. <br /> 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) <br /> days after receipt of application. The files_ will be held for a maximum of five business days fo review. Appointment$ <br /> should be scheduled accordingly. 914 717a-" <br /> 3. A file that is actively being worked on by EHD staff rhay 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 s 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 deposit prior to review. <br /> EHD USE ONLY <br /> 1 <br /> EHD 48-06 8104108 PUBLIC RECORDS RELEASE APP FORM <br />