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11/30/2009 11:54 FAX p002/002 <br />.jj4w D ,4'p, X141OP.nl Nil (� OUN7 Y EHD LOG NUMBER <br />._. <br />NOV 3 0 2009 ENVIRONMENTAL HEALTH DEPARTMENT <br />p�T{� 600 East Mala St. Stockton, 01 8 520302427 <br />/ <br />E��(�(J�i♦V)��' }�Il�h'one: (209) 468-342D Fax: (209) 464-0138 Web: www,sjgov.org /v/A JPUBLIC RECORDS RELEASE APPLICATION T <br />APPLICANT: v C �R BUSINESS/AGENCY: i 3a' J1G�S f 114 C - <br />ADDRESS: c_ CITY/STATE/ZIP: r1S-S2-/ <br />PHONE (1): (�/��q3v—o23y PHONE (2): C9(6)eyq^219 16 FACSIMILE: A, 4Pi0^—OG o7- <br />TENTATIVE' APPOINTMENT DATE: I%/3�o9 Time: OSC?D <br />�( (Please allow 10 business days from data of eppliwtivn submittal - •Tentative only - must be confirmed) <br />LI CHECK BOX TO EXPEDITE REO - 75 F (CA OR CHEGK ONLY)- REQUEST PROCESSED IN 3 BUSINESS/DAYS <br />SIGNATURE OF APPLICAN DATE 11 <br />Electronic Information: ❑LIS Map - Description: <br />FILE -ADDRESS EHD USE ONLY <br />Street it Street Name City l7an i. <br />2._ <br />to <br />��ENViRONMENTAL HEALTH DEPARTMENT FILE8 <br />NDERGROUND TANK (UST) CL PiSnl (OP) ❑ HOUSING ABATEMENT <br />OTHER CLEANUP SITE (NON LO ❑ FOOD FACILfrY <br />0 GO 2 <br />SL(3 <br />bJ• U PA�� <br />❑ DOG KENNEL <br />3. <br />y 7 <br />I.t/)1 1 J I <br />�?6f�DERGROUND <br />�'HAiARDOUS WASTE GENERATOR <br />_ <br />j� i 11, (0 >uwt <br />4. <br />I TIERED PERMITTED FACILITY <br />W I L I <br />❑ PUMPER TRUCKIYARDICHEMICAL TOILETS <br />S. <br />217S <br />1SLY0 t4 <br />00 c//h <br />Unit <br />8. <br />7. <br />Unit 5 <br />8. <br />B, <br />IT unit s <br />10. <br />J <br />I h7 <br />Specific Data Range of Information Re uefvd. Fro <br />to <br />��ENViRONMENTAL HEALTH DEPARTMENT FILE8 <br />NDERGROUND TANK (UST) CL PiSnl (OP) ❑ HOUSING ABATEMENT <br />OTHER CLEANUP SITE (NON LO ❑ FOOD FACILfrY <br />❑ SOLID WASTE FACIHTYNEHICLE <br />❑ WASTE TIRE <br />)"(/ <br />y�f�J <br />` . <br />TANK (MONDORINOI'( MOYAL) � <br />❑ DOG KENNEL <br />❑ DAIRY <br />y 7 <br />I.t/)1 1 J I <br />�?6f�DERGROUND <br />�'HAiARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ WASTEWATER TREATMENT PUNT <br />17-11 <br />I TIERED PERMITTED FACILITY <br />❑ MOTEL/HOTEL <br />❑ PUMPER TRUCKIYARDICHEMICAL TOILETS <br />TATT-OoMoDY PIERCING <br />❑ PDOUSPA <br />❑ LAND USE APPLICATION SnES <br />I MEDICAL NIASTE FACILITY ❑ OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:011PM (EXCLUDING HOLIDAYS) <br />1. List up to ten addresses In the apace above. Select the typo(s) of files from the list above by checking the appropriate <br />box(es), At least one file type MUST be selected. Fax to (2091404-0138 or mail to the address Indicator ve. 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 appointment for review will be confl mod 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 Nle 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. N you need further assistance, please contact Diane Martinez, at (209) 408-3425. W p� <br />, H -K) awn USF ONLY <br />is !tJ t I/ • t a .l 1.��� <br />EHO U-06 <br />