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10/13/2011 14: 15 9166486688 ADP PAGE 01/01 <br /> RECEIVED 0 SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> (96,f 1. 3 2011 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> ENVIRONNIIENFAL HEALW41ephone: (209)408-3420 Fax; (209)464-0138 Web: www-sjgov.org/ehd <br /> P ERN1 IT/S E RVI C E'S 60 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: q&;1S 14(j,�k� SUSINESS/AGENCY:App, <br /> ?� 3&T71 _,4_20 el <br /> ADDRESS; CIMSTATE/ZIP: <br /> PHONE(1): PHONE(2) q6 I j 7 FACSIMILE: <br /> TFIVTA TIVE*APPOINTMENT DATE:- Time: <br /> (Please allow 10 business days from date Of�Application submittal-'Tentative onli—MuSt be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE RE EST-$125, "E(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 13PSINE DAYS <br /> SIGNATURE OF APPLICANT I DATE_h <br /> Electronic Information: El List[I Map-Description: <br /> FILE ADDRESS EHD <br /> A0MA <br /> ,USE ONLY <br /> Street# Street Name City ' <br /> k�Un I <br /> 2. _ <br /> Unit2 <br /> 3. <br /> 4, <br /> k. <br /> A I Jr,Ai 3 unit <br /> 3 IV, <br /> nit <br /> .5. <br /> 6. <br /> 4 <br /> 7. '25"Unit U'R4 <br /> 8. <br /> 9. El units <br /> 10. <br /> Elunit� <br /> ._j <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> V UNDERGROUND TANK(UST)CLEANUP SITE(LOP) El HOUSING ABATEMENT <br /> SOLID WAST[FACILrrY/VEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) El FOOL)FACILITY ❑WASTE TIRE <br /> [Al UNDERGROUND TANK(MONITORINGIREMOVALCk, Ej DOG KENNEL ❑DAIRY <br /> HAZARDOUS WASTE GENERATORN n CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY El MOTELIHOTEL ❑PUMPER TRUCK/YARD/CHEMICAL TOILETS <br /> ❑TATTOO/BODY PIERCING D POOLISPA ❑LAND USE APPLICATION SITES <br /> El MEDICAL WASTE FACILITY [j COMPLAINT RECORDS 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 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)4134-0138 or mail to the address indicated above. Address <br /> ranges will not be accepted-for additiona(aseletanco 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 aPP[leati*n. The files will be hold 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 appileant. <br /> Future file reviews by the same applicant may require a$125 deposit prior to review. <br /> EEO USE ONLY <br /> EHD 48.06 <br />