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RE GEIVE D <br />SAN .1QA EHD LOG M � <br />QUIN COUNTY R- <br />NOV 15 2010 ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main St. Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.org/e <br />ENVIRONMENTAL HEALTH <br />-PERMIT/SERVICES- PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT:_- e i-) Ci BUSI JESSlAGENCY: <br />ADDRESS: 4 4 CITY/STATE2IP: <br />PHONE 1 � - � / � u <br />): F -� PHONE (2)._ 10 J` - 9 j FACSIMILE: �� <br />TENTATIVE* APPOINTMENT DATE: <br />(Please allow 10 business days from date of application submittal - `Tentative onl Time: <br />y -must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST- $122 FEE (CASH OR CHECK ONLY)- REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE <br />Electronic Information: L List ❑ Map — Description: <br />Specific Date Range of Information Requested: <br />IDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />FHER CLEANUP SITE (NON -LOP) <br />IDERGROUND TANK (MONITORINGIREMOVAL)�y <br />1ARDOUS WASTE GENERATORS <br />:RED PERMITTED FACILITY K <br />TTO0/$ODY PIERGNG <br />EDICAL WASTE FACILITY <br />HOUSING ABATEMENT <br />F000 FACILITY <br />15)CIG KENNEL <br />CHICKEN RANCH <br />MOiELMOTEL <br />POOLISPA <br />OTHER (PLEASE SPECIFY) <br />ri <br />I WASTE FACILITY/VEHICLE <br />E TIRE <br />EWATER TREATMENT PLANT 11-17-10 <br />ERTRUCKIYARDICHEMICAL TOILETS <br />USE APPLICATION SITES <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:00PM (EXCLUDING HOLIDAYS) <br />9- List u3 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 (2091464.0938 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 appointmentfor 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 $122 deposit prior to review. <br />Z -d 088L -L65-9 Lb <br />e316010aE) d�S:ZO OL SL A0N <br />