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IIAT'RECENED <br />SAN .1QAQUIN COUNTY <br />EHD LOG NUMBER <br />01_-1 <br />24 2011 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main St. Stockton, CA 95202-3029 <br />�108W: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.arg/ehd <br />FivvP RM01SE.?"":"�S PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: ..dry ot\--, V\-, „BUSINESS/AGENCY: <br />ADDRESS: 3,139 CITY/STATE/ZIP: 25f:�_ <br />PHONE (1): qZ � Ljgo• zea ,' PHONE (2): FACSIMILE:'?/d ygp.Q,Sp3 <br />TENTATIVE" APPOINTMENT DATE: p� Time: <br />(Please allow 10 business days from date of application submittal - "Tentative only - must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQ EST - $1 2 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE .;Z V- i % <br />Electronic Information: D List7 Map — Description: <br />.�j <br />❑ SOLID WASTE FACILfrYNEHICLIE <br />FILE ADDRESS <br />END USE ONLY <br />❑ FOOD FACILITY <br />Street # Street Name <br />city <br />❑ DOG KENNEL <br />❑ CHICKEN RANCH <br />❑ DAIRY <br />❑ WASTEWATER TREATMENT PLANT <br />Ci �j <br />Init <br />❑ MOTELIHOTEL <br />❑ PUMPER TRUCK/YARD/CHEMICAL TOILETS <br />❑ TATTOO/BODY PIERCING <br />❑ POOLISPA <br />-r4. C.td �J! <br />❑ MEDICAL WASTE FACILITY <br />.� <br />Unit 4 <br />6. <br />7. <br />_ <br />❑ unit S <br />8. <br />T <br />D Unit B <br />10. <br />Soecific <br />Date Rance of information Reeuested- From re <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT <br />.�j <br />❑ SOLID WASTE FACILfrYNEHICLIE <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />❑ WASTE TIRE <br />UNDERGROUND TANK (MONITORING/REMOVAL) 'tiC <br />HAZARDOUS WASTE GENERATOR` <br />❑ DOG KENNEL <br />❑ CHICKEN RANCH <br />❑ DAIRY <br />❑ WASTEWATER TREATMENT PLANT <br />❑ TIERED PERMITTED FACILrTY <br />❑ MOTELIHOTEL <br />❑ PUMPER TRUCK/YARD/CHEMICAL TOILETS <br />❑ TATTOO/BODY PIERCING <br />❑ POOLISPA <br />❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY <br />❑ OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORD$ ARE AVAILABLE FOR REVIEW. MONDAY -FRIDAY 8:00 AM•5:00PM (EXCLUDING HOLIDAYS) <br />1. List uo 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 (2091464-0138 or mall 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 flies 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 $122 deposit prior to review. <br />L00/L00In <br />XVI Ll ll LLOd/bZ/Ol <br />