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6 <br />/ST 12'S5/No•7500000321 <br />nE <br />� <br />'�merltal 1r.r--. � <w�0)MflR 10 241Q 12.5� <br />D F: <br />SAN JpAQUIN COUNTY' <br />LIAR 4 U N1 < ENVIRONMENTAL HEALTH DEPARTMENT <br />ENVIRONMENT HEALTHCie" <br />� � 600 East Main St. Stockton, CA 95202-3029 <br />��R �-'��R���one: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: It �dli`eW J�':'w Q <br />ADDRESS: i -S33 F S C <br />PHONE (1):.s��-o�.47'�� '' a BONE (2):_ <br />TENTATIVE' APPOINTMENT DATE: ,3" I <br />(urease allow'10 business days from date of app[ <br />BUSINESS/AGENCY: <br />CHECK BOX TO EXPEDITE REQUEST - $115 F A5 OR CHECK ONL <br />SIGNATURE OF APPLICANT _ <br />EHD LOG NUMBER <br />,4�-n vi flo n <br />'ATEIZIP: 40- <br />FACSIMILE:316 `832 <br />Time: <br />only -'must be c <br />T:PROCESSED <br />DATE <br />unnnuau� <br />IN 3 BUSIN��l]Q <br />Electronic Information: <br />Street 9 <br />❑ List ❑ Map – Description: <br />FILE ADDRESS <br />Street Name <br />City <br />EHD USE ONLY <br />© Unit t <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />[:]SOLID WASTE FACILITYNEHICLE <br />7HER CLEANUP SITE (NON -LOP) <br />5`� ' � � .r <br />❑ Unit 2 <br />2. A43 �-, , +ow� S�C,eA- <br />S an # <br />El DAIRY <br />,HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ WASTEWATER TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY <br />❑ MOTELIHOTEL <br />ZUn3 <br />4. 0 <br />❑ POOLISPA <br />5. <br />❑ MEDICAL WASTE FACILITY <br />❑ OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:40 AM-5:00PM (EXCLUDING HOLIDAYS) <br />7. <br />s <br />8.❑UnitAir <br />9. <br />' `P�. A <br />cl Unit -Si <br />10r 5i " <br />Specific Date Range of Information Requested: <br />Fromm f*- <br />to <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />[:]SOLID WASTE FACILITYNEHICLE <br />7HER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />❑ WASTE TIRE <br />,UNDERGOROUND TANK (MONITORINGIREMOVAL) <br />El DOG KENNEL <br />El DAIRY <br />,HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ WASTEWATER TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY <br />❑ MOTELIHOTEL <br />❑ PUMPER TRUCKNARDICHEMICAL TOILETS <br />❑ TATTOOIBODY PIERCING <br />❑ POOLISPA <br />❑ LAND USE APPLICATION SITE$ <br />❑ MEDICAL WASTE FACILITY <br />❑ OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:40 AM-5:00PM (EXCLUDING HOLIDAYS) <br />1. List un to tan 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 N 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 />