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12/30/2005 08:11 FAX 510 420 'x' CAMBRIA 119001 <br /> v� c rvc%-crvty EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY 1k <br /> r [D� <br /> E�`� E� ENVIRONMENTAL ALTH[DEPARTMENT <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202-2708 <br /> U C U Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> =a-immulPNT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> API�[f ,! <br /> BUSINESS/AGENCY: die-1 .a 6�1rneeit��c /Z <br /> ADDRESS: 5940 o%�✓ c�l� u/ �,s{ di E- y`714 o ,' <br /> PHONE(1): /¢ PHONE(2): pL <br /> //� FACSIMILE: $'Yo � <br /> TENTATIVE*APPOINTMENT DATE:.,A4,vFr /3Zoo Time:®`lam <br /> (Pleas®allow 10 business days from date of application submittal-"Tentative only-must be confirmed) <br /> ® CHECK BOX TO EXPEDITEREQUEST-$93,00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT -- DATE ,eexc ace �,a -- <br /> - 5 <br /> UNIT DISTRIBUTION ❑Unit 1 ❑Unit 2 O Unit 3 ❑Unit 4 ❑Unit 5 ❑ Unit 6 ❑ Other(eiectronicllists/maps) <br /> FILE ADDRESS <br /> Street# Street Name City, END USE ONLY <br /> 2. 2slS bo : <br /> 3. <br /> s. <br /> 4. <br /> 5. <br /> 6. " <br /> a. <br /> 7. <br /> L160- <br /> Specific Date Range of Information Requested:From .Aa 444,-- to <br /> OOTHEP <br /> ENVIRONMENTAL HEALTHDEPARTMENT FILESNDERGROUNO TANK(UST)CLEANUP SITE(LOP) 13HOUSING AsATEmEmT 13SOLID WASTE FACILITYNEHICLE <br /> CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> „WUNDERGROUNDTANK(MONITORINGIREMOVAL) ❑DOG KENNEL ®DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMnTED FACILITY ❑MOTEL/HOTEL ❑PUMPER TRUCKIYARD/CHEM ToiLETS <br /> ❑TATroO/BoDY PIERCING 13 POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑MEDICAL WASTE FACILITY E3 OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW MONDAY-FRIDAY 8:00 AM-5i: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(2091464-0138 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 /> r. <br /> t <br /> EHD 4842-06 <br /> IMMS <br />