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DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> 0 C 1 1. 1 2 Alephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> PERM117SERVI ES <br /> P4 �r P'; ,� <br /> APPLICANT: BUSINESS/AGENCY: <br /> ADDRESS: 7y1°4,,vN c---FCITY/STATE/ZIP: TU/? L vC•� c>q s"3g <br /> PHONE (1): �441- PHONE (2): Z oq 6 4 - /i r 1 FACSIMILE: _ <br /> TENTAT/VE*APPOINTMENT DATE: Time.-- <br /> (Please <br /> ime:(Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST 125 FEE(CAS OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE I — I I - 1 1 <br /> Electronic Information: ❑ List❑ Map- Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑ Unit 1 <br /> 2. i r; HA >Q��'� L /�c�To �• l� ❑ Unit2 <br /> 3. <br /> 4. nit 3 1� <br /> 5. Iq <br /> 7. <br /> 8. <br /> ❑ Unit 5 <br /> 9. <br /> 10. ❑ Unit 6 <br /> Specific Date Range of Information Requested: From to ��` <br /> y ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> E'6,616ERGROUNDTANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYIVEHICLE `\ <br /> 0"O�,/THER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE r��^A\ <br /> ❑.l1NDERGROUND TANK(MONITORINGIREMOVAL)X ❑DOG KENNEL ❑DAIRY �O,� 1 <br /> tRED <br /> 2ARDOUS WASTE GENERATOR'! ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT PERMITTED FACILITY-- ❑MOTELIHOTEL ❑PUMPER TRUCKIYARD/CHEMICAL TOILETS <br /> ❑TATTOOIBODY PIERCING ❑POOL/SPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑COMPLAINT RECORDS ❑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?immdJJ"ately.av ' able for rev'p. Anew appIic t012 may ¢�,U <br /> submitted when the file is available. ��� ��� : �W �'j'/71�- � z'►� /1��yi��,�/►rg Uw <br /> 4. Any file not returned in the same condition as releas�d win be reor n e�l`� stat �tp��iS'�of hal �plic rit.� <br /> Future file reviews by thesame applicant may require a$125 deposit rior to review. ip, Z0 1 ; n <br /> EHD USE ONLY 1yM� 3 2 I -7 L r l <br /> a <br /> 3 al -W �3 <br /> in 6-T;147� <br /> -I �l 11 _I/1 .�-I 5 v- & illy rPf <br /> EHD 48-06 6] 106inll1h(�/�15j. 3}��- l/Qi�n.a. IAIr716�P, #5L/l use, Py <br />