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DATE RECEIVED EHD LOG NUMBER <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />FILECOPY PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: /, -i�� e ,O/'`jJZ&&2 BUSINESS/AGENCY: <br />ADDRESS: 62f5_ -5E—, %'iiia Girl "'P7 � _ - CITY/STATE/ZIP:�2Cr_e <br />PHONE (1): -140—6�_;3-7 PHONE (2): FACSIMILE: ('ec-j7 <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 - $125 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT <br />DATE <br />Electronic Information: ❑ List ❑ Map — Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />❑ Unit 1 <br />❑ UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />Street # <br />Street Name <br />City <br />UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ DOG KENNEL <br />AZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ Unit 2 <br />2• <br />❑ TATTOO/BODY PIERCING <br />❑ POOLISPA <br />❑ MEDICAL WASTE FACILITY <br />3. <br />❑ Unit 3 <br />4. <br />5. <br />❑ Unit 4 <br />6• <br />7. <br />❑ Unit 5 <br />8. <br />9. <br />❑ Unit 6 <br />10. <br />Specific Date Range of Information Requested: From <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT FILES <br />❑ UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />❑ OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ DOG KENNEL <br />AZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ TIERED PERMITTED FACILITY <br />❑ MOTELIHOTEL <br />❑ TATTOO/BODY PIERCING <br />❑ POOLISPA <br />❑ MEDICAL WASTE FACILITY <br />❑ COMPLAINT RECORDS <br />to <br />❑ SOLID WASTE FACILITYIVEHICLE <br />❑ WASTE TIRE <br />❑ DAIRY <br />❑ WASTEWATER TREATMENT PLANT <br />❑ PUMPER TRUCKNARD/CHEMICAL TOILETS <br />❑ LAND USE APPLICATION SITES <br />❑ 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 $125 deposit prior to review. <br />