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01/id/2I717y 15:44 40BB650122 PAGE 01/01 <br /> DATE REG(w1yE E <br /> p �`—'� SAN EHD LLOGNUM6ER <br /> R I E ENVIRONMENTAL <br /> COUNTY <br /> AL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3429 <br /> �i-,N 13 2009 Telephone: (209)468-3420 Fax; (209)464-0138 Web: www.sjgo d <br /> ENVIRONMENT HEALTH <br /> PET� PUBLIC RECORDS RELEASE APPLICATION <br /> - <br /> APPLIGANT: BUSINESS/AGENCY: <br /> ADDRESS: City/5tatelZlp 12-1? <br /> PHONE(1); 0122,PHONE(2): FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time; <br /> (Please allow 10 business days from date of application submittal-'7enfe6ve only-must be confirmed) <br /> C1 CHECK BOX TO EXPEDITE REQUEST-$105 E CASH OR CHECK ONLY)-REQUEST PROCESSED IN 9 USINESS DAYS <br /> SIGNATURE OF APPLICANT DATE l /3 p <br /> Electronic lnformatlon: ❑ List❑Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City <br /> ' 1. (] volt <br /> 0r- <br /> 2. � <br /> a. <br /> 0Unit 2 <br /> 4. a <br /> Unit'4 �\ <br /> 7. <br /> © Unit 5 <br /> 9. <br /> 10. CI Unit 6 <br /> Specific Date Range of Information Requested:From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> f <br /> DERGROUND TANK(UST)CLEANUP SITE(LOP) 0 HOUSING ABATEMENT CI SOLID WASTE FACiUTYIVEHICLE ,9,^HER CLEANUP SITE(NON-LOP) 0 FOOD FACILI Y 0 WAST12 TIRE l�WI/DERGROUND TANK(MONITORINGIREMOVAL)Ot 0 DOG KENNEL 0 DAIkY K `-�ZARDOUS WASTE GENERATOR O CHICKEN RANCH 0 WASTEWATER TREATMENT PLANT <br /> RED P-RmlrrED FACILITV{ 0 MOTEL/HOTEL 0 PUMPER TRUCK/YARD/CHEM ToILETs <br /> TToo1BODY PIERCING 13 POOUSPA EI LAND USE APPLICATION SITES <br /> ©MEDICAL WASTE FACILITY 0 OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS-ARE AVAILABLE FOR REVIEW-MONDAY-FRIDAY B:OQ AM-5:Q0PM -EXCLUDING HOLIDAYS. <br /> 1. List up to ten addresses in the space above, Select the type(s)of files from the first above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(Z09)464-0188 or mafl 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 /> 8:00 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 /> 8. A file that Is actively being worked on by EHO staff may not be Immediately avallable 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 deposit prior to review. <br /> EHD USE ONLY <br /> EHD 48-06 8/04/o6 PUBLIC RECORDS RELEASE APP FORM <br />