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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 q1573 <br /> n' � � ��yP"�UBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT-�u?,/-�� ✓t.(./l.lL �( ,� BUSINESS/AGENCY(- CC'i' isa�e y I�2Z Cts <br /> ADDRESS:_/ I S c[Cth S f u � I CITY/STATE/ZIP Olt 161a"-d <br /> PHONE(1): Sim Z 2- 2 /CSU 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 /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name - City _ - — ❑ Unit 1 <br /> 2. <br /> 7G LU.j.SCn't ww l �- 3C, („ El Unit 2 <br /> 5. <br /> 6. -- Unit 4 <br /> 7. ?00F, <br /> 8- Unit 5 <br /> 9. <br /> 10. ❑ Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ID�1NDERGROUND TANK(UST)CLEANUP SITE(LOP), ❑ HOUSING ABATEMENT M SOLID WASTE FACILITY/VEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY M WASTE TIRE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> .2T HAZARDOUS WASTE GENERATOR ` \ ❑ CHICKEN RANCH WASTEWATER TREATMENT PLANT <br /> .TIERED PERMITTED FACILITY �1 MOTEL/HOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> 13 TATTOO/BODY PIERCING POOL/SPA <br /> 11 O LAND US PPJLICATION ITES <br /> t7 MEDICAL WASTE FACILITY `, ❑ OTHER(PLEASE SPECIFY)`��C J N q/{ti�,� C` <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 4"6 <br /> AMAOMA <br />