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DATE RECEIVED EHD LOG NUMBER <br /> SAN .1OAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.or <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: - ,t ?� _ 1� � BUSINESS/AGENCY: /Ue� ccs^ /lam <br /> ADDRESS: Z7� ��L` G���)l / CITY/STATE/ZIP: -'4-k7 6- —4p� em �%j. <br /> PHONE (1): 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-$115 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 /> 1. cr 6 a a G� "7 Cr � OC' <br /> nit 2 <br /> 4. j�: S r �ra_s V e Afnit 3 <br /> 5. 1Y ss a ) W,`e,9-047 <br /> 6. tl bit q <br /> s. <br /> ❑Unit 5 <br /> 9. <br /> 10. <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 ❑SOLID WASTE FACILITYIVEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> ,UNDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL ❑DAIRY <br /> .�HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH <br /> El WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY <br /> ❑MOTEL/HOTEL ❑PUMPER TRUCKNARD/CHEMICAL TOILETS <br /> ❑TATTOO/BODY PIERCING ❑POOL/SPA �2 LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑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�uy 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 deposit prior to review. <br /> 5. If you need further assistance, please contact Diane Martinez,at(209)468-3425. <br /> EHD USE ONLY <br /> EHD 48-06 <br /> 8/27(09 <br />