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DATE RECEIVED EHD LOG NUMBER <br />SAN .10AQUIN COUNTY �/�•,• <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main St. Stockton, CA 95202-2708 <br />JUL 2 '2 14elephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/e <br />ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT:_ MA(S,,ALIa-Ar�SUSINESSIAGENCY:t,,&j l5-_G1-�.lW <br />ADDRESS: 2-22 Int LAS QLl1J�S �LV�.CITY/STATE/ZIP: <br />PHONE ( HONE (2): FACSIMILE: 44a - `fib' I s-qGi <br />TENTATIVE* APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application submittal -'Tentative only -must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST - $115.00 FEE (CASH O ECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT!�� - DATE 22,UL 2 Ol0 <br />Electronic Information: ❑ List ❑ Map - Description: <br />ENVIRONMENTAL <br />FILE ADDRESS <br />EHD USE ONLY <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />Street# <br />Street Name <br />City <br />1• <br />1313 <br />STdC!~roN 6T <br />1_ob 1 <br />�5TD2 I , <br />nit 2 <br />2. <br />❑MOTELIHOTEL <br />PUMPERTRUCKIYARDICHEMICAL TOIL S��o <br />TATToofflwY PIERCING <br />3. <br />❑ LAND USE APPLICATION SITES <br />MEDICAL WASTE FACILITY <br />❑ OTHER (PLEASE SPECIFY) <br />nit 3 <br />4• <br />S. <br />4 <br />6.It <br />7. <br />❑ Unit 5 <br />8• <br />9. <br />Unit 6 <br />10. <br />Specific Date Range of Information Requested: From r$Ffol N NI M& b1'' Tl lam?; to IVW = 5=�w D>A <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />�(�( <br />® SOLID WASTE FACILRYNEHICLE <br />1 <br />"�' <br />OTHER CLEANUP SITE (NON -LOP) <br />UNDERGROUND TANK (MONITORINGIREMOVAL) (x <br />❑ FOOD FACILITY <br />El DOG KENNEL <br />WASTE TIRE V\' <br />DAIRY� <br />id HAZARDOUS WASTE-GENERATOROL• <br />❑ CHICKEN RANCH <br />WASTEWATER TREATMENT PLANT p <br />TIERED PERMITTED FACILITY pI. <br />❑MOTELIHOTEL <br />PUMPERTRUCKIYARDICHEMICAL TOIL S��o <br />TATToofflwY PIERCING <br />❑ POOLISPA. <br />❑ LAND USE APPLICATION SITES <br />MEDICAL WASTE FACILITY <br />❑ OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW MONDAY -FRIDAY 8:00 AM-5:OOPN1(EXCLUDING HOLIDAYS) <br />1. List up 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_(209) 464-0138 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 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 $115.00 deposit prior to review. <br />0 <br />