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DATE RECEIVED <br /> . SAN .10AQUIN COUNTY F1 A CopyHD LOG NUMBER <br /> I� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> PUBLIC, _Rf�ECORDS RELEASE APPLICATION <br /> APPLICANT: GhVVM6' PttyxP�wt� BUSINESS/AGENCY: ,5 Ayl f (_. <br /> ADDRESS: 13$; N M&D©wel( S vtij�_ Z-3'0 CITY/STATE/ZIP: <br /> PHONE (1): _70'j— PHONE(2): FACSIMILE: -7U-7 — -7(o_S — ego g <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-$122 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT & - J ev( � DATE 4(Q1 f <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑Unit 1 <br /> 1. 1 -711 p ' i �1/�-C dV(CvV1 �f Com+ <br /> 2. <br /> ❑Unit 2- <br /> 3. <br /> 4. <br /> ❑Unit 3 <br /> 5. <br /> 6. <br /> ❑ Unit 4 <br /> 7. <br /> 8. <br /> ❑Unit 5 <br /> 9. <br /> 10. <br /> ❑Unit 6 <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 FACILITYNEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL ❑DAIRY <br /> ❑HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTELMOTEL ❑PUMPER TRUCKNARDICHEMICAL TOILETS <br /> ❑TATTOO/BODY PIERCING ❑POOL/SPA ❑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 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$122 deposit prior to review. <br /> EHD USE ONLY <br /> &,'n 0-7 S65 - 'Tg09 <br /> 3 r/ <br /> EHD 48-06 07/29/10 <br />