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FEB-4-2010 11:47A FROM:GEOPHASE�U 2095690295 T 40138 P.2 <br /> � G NUMBER <br /> \(`vJln SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> FEB 0 4 2010 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd ) <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> PER APFLICANT:1 Ia.er BUSINESSIAGENCY: WO <br /> ADDRESS: .2 ,?337 City/State/Zip A-�f7tv T <br /> PHONE(1): 5W PHONE(2): FACSIMILE:15169 0�9J <br /> TENTATIVE`APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-•Tenretive only-must b0 confirmgd)•• .' •• • • .' <br /> CHECK BOX TO EXPEDITE REQUEST•$105 FEE CASH OR CHECK ON Y)-REQUEST PROCESSED IN 3 BUSINE• <br /> SIGNATURE OF APPLICANT,,;�_� DATE <br /> Electronic Information: ❑ List❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street• Streot Namo City _ ❑ Unit 1 <br /> ❑ UnIt2 <br /> 2. 8'boo_ 3' �o�ec.ylr ._ •• <br /> 3. - <br /> - <br /> 4. <br /> 6 nit 4 <br /> 6. J. `:. <br /> T• <br /> 8: x <br /> 9. ❑ Unit e <br /> 10• <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> /�IJNDERGROUND TANK(UST)CLEANUP SITE(LOP) O HOUSING ABATEMENT M SOLID WASTE FACILITYNEHICLE <br /> N OTHER CLEANUP SITE(NON-LOP) O FOOD FACILITY 17 WASTE TIRE <br /> �O`UNOERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL 0 DAIRY <br /> 0 HAZARDOUS WASTE GENERATOR Cl CHICKEN RANCH 0 WASTEWATER TREATMENT PLANT <br /> 0 TIERED PERMITTED FACILITY 0 MOTELMOTEL 0 PUMPER TRUCK/YARDICHEM TOILETS <br /> 0 TATTOOIBODY PIERCING 0 POOLISPA 0 LAND USE APPLICATION SITES <br /> MEDICAL WASTE FACILITY D OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW - MONDAY-FRIDAY 8:00 AM-6:00PM - EXCLUDING HOLIDAYS- <br /> 1. List up to ten addresses in the space above. Select the typos)of files from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(2091464-0138 or mail to the address indicated above. Address <br /> ranges will not be accepted-for additional assistance with tile 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$106 deposit prior to review. <br /> EHD USE ONLY <br /> EHD 48-06 8/09/09 PUBLIC RECORDS RELEASE APP FORM <br />