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D T REEED <br />IVED SAN JOAQUIN COUNTY <br />IV EWIRONMENTAL HEALTH DEPARIIGIENT <br />JAN 29 2013 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />ESIRONMENTAL P RMITSERVICELTH PUBLIC RECORDS RELEASE APPLICATION <br />EHD LOG NUMBER <br />APPLICANT: J /7, BUSINESSIAGENCY: Cna-l�1TC3r"` <br />ADDRESS: ��� W ' CP N� �It1i r CITY/,S,,��TATE/ZIP: a G <br />PHONE (1): tl'7'3L43' {Jy4� PHONE (2): gIfi/`'�'II� "2-'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 EXPEDITER ST- $125 FE 'CASH OR CHECK ONLY) -REQUEST PROCESSED IN 3 BLISINE DAYS <br />SIGNATURE OF APPLICAN DATE ( Z- <br />Electronic Information: <br />❑ Lis ❑ Map — Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />❑ Unit 1 <br />Street # <br />Street Name City <br />1. <br />55 <br />INA I <br />I �� �t <br />It 2 <br />n1J <br />Unit 3 <br />2. <br />3.OlCt1 <br />4- <br />5. <br />To view the HMMP (Hazardous <br />Materials Management Plan) go to the <br />following website: www.sjoesdata.org <br />nit 4 <br />❑ Unit 6 <br />❑ unit s <br />6, <br />7. <br />6, <br />9 <br />10. <br />Specific Date Range of Information Requested: From to (�- <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />ONDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE FA�CIUTYIVEHICLE <br />THER CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT ❑WASTE TIRE qrN h✓�le5<f%i(J/ll r'3 <br />allNDERGROUND TANK(MONITORINGIREMOVAL)❑F6 <br />� FOOD FACILITY <br />DAIRY a/Iii/3 <br />ABOVEGROUND TANK ❑ CHICKEN RANCHI DOG KENNEL ❑ WASTEWATER TREATMENT PLANT <br />�PAZARDOUS WASTEIH�IAX4 Al ❑ MOTELIHOTEL PUMPER TRUCKIYARDICHEMICAL TOILETS <br />1 TIERED PERMITTED FACILITY ❑ POOLISPA W LAND USE APPLICATION SITES <br />D TATTOOIBODY PIERCING ❑ COMPLAINTIRESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:OOPM (EXCLUDING HOLIDAYS) <br />1. List up to ten addresses in the space above. Select the types) 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 $125 deposit prior to review. —*BOXED AREA - EHD USE ONLY*"' <br />EHD 4d-06 <br />t /l II ■ t . i ��7Jf"rU!—'S•���HI!(t��/ � , I •I d � -_ / � <br />