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.n 23 2012 1 : O1PM �P LASERJET FAX <br /> p. 2 <br /> DATE RECEIVED <br /> SAN JOAQUINCO N u EHD LOG NLJMBER <br /> ENVIRONMENTAL HEALTH DEPARTMENT (� <br /> C EN"Rb., 900 East Main St. Stockton, CA 95202-3029 4 �" <br /> I `'lone: (209) 468.3420 Fax: (209) 464-0138 Web: WWW.8190v.or9lehd ` '^ D <br /> 3AN 21 PUBLIC RECORDS RELEASE APPLICATION <br /> APE ��{{ � -�+ LI BUSINESSIAGENCY:_5{S )GC giyi�uM (l7ht~ <br /> ADD49: 6l 17-7m S'( Al 247 CITYISTATEIZIP: oK-L"o C4 <br /> PHONE(1): tno fg 36t of b oI°I PHONE (2)yy- FACSIMILE: 5T9 <br /> TENTATIVE'APPOINTMENT DATE: I/!,I I ?— b <br /> (Plesse allow 10 business from date ora Iltatlon submittal-• Time: I m �, <br /> PP livrdaHvs only-must be confirmed) <br /> ,�CHECK BOX TO EXPEDIT ES E(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 USIN 88 DAYS <br /> SIQNATURE OF APPLICAN DATE l -J- <br /> Electronlc Information: ❑ List❑ M p Description: <br /> FILE ADDRESS 0 USE ONLY <br /> street# street Nem* City <br /> t i2 �A/ I,OG}G�"rp � �� t <br /> 2. OZ v2 EJ �`1I Isss,ttt <br /> 3. <br /> "I S Unit2 ci/� <br /> 4. tr <br /> (, Z/—/Unit3 <br /> ) <br /> 8. <br /> T UnIt 4 <br /> ® Unit 6 <br /> 10, <br /> Unit 0 <br /> Specific Date Renes of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILER <br /> ERVNDEROROUNO TANK(LIST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT OLID WASTE FAC1LrnfNEHk)LE IQ <br /> E;CfHER CLEANUP SITE(NON-LOP) ©FOOD FACILITY ❑WASTE TIRE <br /> �CtTNAG ROROUNDTANX(MONIrORINGIREMOVAL)V_ ❑DOG KENNEL ❑DAIRY WWi <br /> ARDOUS WASTE GENERATOR O', ❑CHICKEN RANCH (I3 I-Z7-I Z- <br /> RED PERMITTED FACILITY ❑WASTEWATER PLANT <br /> ❑MOTELIHOTEL ❑pUMPERTRUCIUYAROICHEMICALTOILET6 <br /> ❑TATTOOIBOpY PIERCING ❑P L/$PA El LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACtrrY PLAINT RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS,ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 Am-6:0 M(EXCLUDING HOLIDAYS) <br /> 1. List uo to tan addressee In the apace above. Select the types)of files from the list above by checking the appropriate <br /> box(as). At haat Ona Mia type MUST be selected. Fax to f20e1484.01 +or mall to the address Indicated above Address <br /> ranges will not be accepted-for additional assistance with Ells Eddreesse,contact the EHD. Applications received after <br /> 8:00 pm will be processed the next business day, <br /> 2. The HHD will notify the applicant If any EHD files exist An appointment for review will be confimned approximately tan(10) <br /> days after reoelpt 0f application. The flies wIn be held fore maximum Of five business days for review. Appointments <br /> should be scheduled accordingly. <br /> 3. A file that Is actively being worked on by EMD staff may not be Immediately available for review, A new Application may be <br /> Submitted when the file In available. <br /> 4. Arty 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$126 deposit prior to review. <br /> ' M 3f I a, <br /> 12 1 <br /> 0 �d 567 A <br /> IHID e <br /> e17n1 <br />