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DATE RECEIVED EHD LOG NUMBER <br /> RECEIVED <br /> ` �E SAN JOAQUIN COUNTY _ <br /> 1 \( ENVIRONMENTAL HEALTH DEPARTMENT 5g 97Aid 5 201 600 East Main St. Stockton, CA 95202-2708 <br /> elephone: (209) 468-3420 Fax: (209) 464-0138 Web: www,sjgov.org/�Chd O�� <br /> MENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: L{ (ULA ' BUSINESS/AGENCY: <br /> ADDRESS: CITY/STATE/ZIP: �j(� f CA <br /> PHONE (1): L�.6G�Qli�7 PHONE(2): 4 ' 14177 FACSIMILEJ�— <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 R EST-$115.00 FEESH OR CHECK ONLY)-REQUEST PROCESSED 1 3 BU NESS DAYS <br /> SIGNATURE OF APPLICANT g=Qjj" <br /> DATE—11 <br /> Electronic Informatioh: ❑ List ❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street 9 Street Name City ❑Unit 1 <br /> t. <br /> ' 0 <br /> 2. Fam ►�i <br /> 3. Unit 2 q <br /> 4. ` / 7 <br /> 5 ❑ <br /> C � V Unit <br /> s. > <br /> 7 ❑Unit <br /> 8. <br /> 9 � � ❑Unit s <br /> 10. pG V �6G <br /> ❑Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY El SOLID WASTE FACILITYNEHICLE <br /> F-1UNDERGROUNDTANK(MONITORINGIREMOVAL) ❑DOG KENNEL [:1 WASTE TIRE <br /> F]HAZARDOUS WASTE GENERATOR El DAIRY <br /> ❑CHICKEN RANCH ❑ STEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTELIHOTEL LlOf PUMPER TRUCKIYARD/CHEMICAL TOILETS <br /> ❑ <br /> TATTOO/BODY PIERCING ❑POOLISPA. <br /> ❑ El LAND USE APPLICATION SITES <br /> MEDICAL WASTE FACILITY <br /> ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW MONDAY-FRIDAY 8:00 AM-S:OOPM(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$115.00 deposit prior to review. <br /> EHO USE ONLY <br /> ***If you need further assistance please contact Diane Martinez direct) @ (209)468-3425. Thank You*** <br /> own sa na <br />