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DATE RECEIVED EHD LOG NUMBER <br /> ..� SAN JOAQUIN COUNTY ..... <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-2708 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.or q/573 <br /> PUBLIC RECORDS RELEASE APPLICATION // J <br /> APPLICANT: _Ie `Lt' c/t 1/�Ki G � BUSINESS/AGENCY'S/1,_1� 6'1�C1 <br /> ADDRESS: L-5 / 5 Z 0-t TI CIN/STATE/ZIP_y2 K(�'-,d <br /> PHONE(1): 5/0 W.�Z Z l OCi 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-$105.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILEADDRESS EHD USE ONLY <br /> Street# Street Name City11Unit 1 <br /> CW <br /> ❑ Unit 2 <br /> 3. --7-701 Ta r <br /> 4. Z j /U . ul�-v C -r !— nit-3 <br /> 5. ?� <br /> 6. nit 4 <br /> 7. <br /> 8. Un(.111IIIIIIIIIIIit 5 <br /> 9. <br /> 10. -- El Unit 6 <br /> L <br /> Specific Date Range of Information Requested: From to <br /> le ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> . JJNDERGROUND TANK(UST)CLEANUP SITE(LOP)r 11 HOUSING ABATEMENT C3 SOLID WASTE FACILITYNEHICLE <br /> BOTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ WASTE TIRE <br /> Rl'UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> .ff HAZARDOUS WASTE GENERATOR (�`\ ❑ CHICKEN RANCH ❑ <br /> TIERED PERMITTED FACILITY A 0 _�y.l`� WASTEWATER TREATMENT PLANT <br /> �l (V„� ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑TATTOO/BODY PIERCING ❑ POOL/SPA <br /> ( LAND US APPLICATION ITES <br /> ❑MEDICAL WASTE FACILITY ✓ ❑OTHER(PLEASE SPECIFY) y' �{ti����S- <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$105.00 deposit prior to review. <br /> EHD USE ONLY <br /> ***If you need further assistance please contact Diane Martinez @ (209)468-3425 directly. Thank You*** <br /> EHD 48-06 <br />