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I�� HI CC <br /> SAN JOAQUIN COUNTY ` <br /> S+V "�01Q ENVIRONMENTAL HE <br /> V <br /> 600 East Main St. Stockton, CADg6202-3029NT <br /> NVIRUNIVIEINT HEAW.'i Telephone: (209)468-3420 Fax: (209)464-013$ Web: wWW-Sjgov,o /eh <br /> PERMIT/SERUfCE�a PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: OL,Iu*-R- Y,y" <br /> ADDRESS: -Crzave BUSINESS/AGENCY: CaNEZTo6A_ IZoVFlZS 4 AfiEocFlT� <br /> fez DRIvr vITE IGq CITY/STATE/ZIP: <br /> PHONE(1): (q I(y)ggy_4iR9S3 RAfIIGHo r PDovg OA <br /> PHONE (2): �n(0)2- - cam <br /> T,ENTAT/VF"APPOINTMENT PATE; ----� FACSIMILE: <br /> (Please allow 10 business days from )d-13—to ar s�°'y=r Time: <br /> ©CHECK BOX TO EXPEDITE REQUEST= PPIIcatlon submittal-"Tentative o U �' Oa wr <br /> 22 . E(C H OR H CK ONLY - y must be confirmed) ^— <br /> SIGNATURE OF APPLICANT ) REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> Electronic Information: DATE �'`2�-t o <br /> ❑ Llst <br /> P- riptl <br /> _FILE ADDRESS <br /> Street# Street Name EHD USE ONLY <br /> 1, 475 _. _ City <br /> 604ZM Al 9- SUPMrkl , <br /> �3 $� Sour Al 2 LRTHRop 295Q� S unlit <br /> 2. � 9G <br /> $. FaaraFk $ l Kw SPEC=.TA1.716.+ WF3T -i �.AIK fyi.T.�ROP kAvTt:c t <br /> 4. AY Ara ❑UnH2 <br /> 5. <br /> MR"rm I� <br /> Uni[3 <br /> 5, <br /> 7. <br /> Unit 4 <br /> 8. <br /> 9. <br /> ❑Unit 5 <br /> 10. <br /> Specific Date Rang of Informa ti,,Requestetl: From Q Unit e <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES to <br /> ®UNDERGROUND TANK(UST)CLEANUp SITE(l,Up) 0 HOUSING ABATEMENT <br /> SOTHER CLEANUP SHE(NON-LOP) 0 FOOD FACILITY 0 SOLID WASTE FACILITYNEHICLE <br /> ®UNDERGROUND TANK(MONITORINGIREMOVAL) ❑POG KENNEL 0 WASTE TIRE <br /> ®HAZARDOUS WASTE GENERATOR 0 DAIRY <br /> RE <br /> Q TIED PERMITTED FACILITY � ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> 0 TATTOOIBODY PIERCING 0 MOTEL/HOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> 0 POOL/SPA 0 LAND USE APPLICATION SITES <br /> 0 MEDICAL WASTE FACILITY El OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> t. Lig up to ten addresses In the space above. Select the types)of files from the list above by checking the appropriate <br /> lwx(os). At(east one fife type MUST be selected. Fax to(20 9) a <br /> 4840138 or mail to fhe addres indicated <br /> ranges will not be accepted-for additional assistance with file addresses,contact the EHD. Applications breceiv d afterove s <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(70) <br /> days after receipt of application. The files will be held for a maximum of five business days for re <br /> should be scheduled accordingly. view. Appointments <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 Pile not raturned in the same condition as released will be reorganized by END staff at the expense of the applicant. <br /> Future file reviews by the same applicant may require a$122 deposit prior to review. <br /> EXD U8E ONLY <br /> FNA dAllf. <br /> n7l7QMn <br />