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DATE RECEIVED tHU LL)U NUMtStK <br />n����V 6AN J®AQuIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />lC 9tihA 12005 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 Apo <br />�` Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd Ir <br />ENVtRONMAct4T HEkJ" I 10D <br />nr_mA►TISERVICES PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: <br />BUSINESS/AGENCY: <br />ADDRESS: <br />PHONE (1): 2��/- %�%3 —�r(/ PHONE (2): FACSIMILE: <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 -1$93.00 FEE (SASH <br />SIGNATURE OF APPLICANT <br />Y) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />DATE ( 1 ^ bS <br />1 UNIT DISTRIBUTION 1 ❑ Unit 1 ❑ Unit 2 jnnit 3 &WTnit 4 ❑ Unit 6 ❑ Unit 6. ❑ Other (electronic/lists/maps) 1 <br />FILE ADDRESS EHD USE ONLY <br />Street # Street Name City <br />1. 2_411 I E, Fa ,_. we o 7- &-r-S �t�� .I <br />S1.2. a -q4 Lr 74 <br />tE. t � n17 -s? <br />Specific Date Range of Information Requested: From <br />to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY/VEHICLE <br />ARM <br />OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ WASTE TIRE <br />UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br />HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ WASTEWATER TREATMENT PLANT <br />Ir <br />TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br />❑ TATTOO/BODY PIERCING ❑ POOL/SPA ❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECIFY) <br />li A <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 <br />appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address <br />indicated above. Address ranges will not be accepted —for additional assistance with file addresses, contact <br />the EHD. Applications received after 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 <br />approximately ten (10) days after receipt of application. The files will be held for a maximum of five business <br />days for review. Appointments 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 <br />application may be 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 <br />applicant. Future file reviews by the same applicant may require a $93.00 deposit prior to review. <br />EHD 48.02-006 <br />11123/04 <br />