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DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> RECEIVED ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> lephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> OCT I , 2��1 �gov.or g <br /> ENVIFIONMENTALHEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> PERMIT/SERVICES <br /> APPLICANT: BUSINESS/AGENCY: <br /> ADDRESS: 2I /�, i y�'l,au,�r �T CITY/STATE/ZIP: TUB [! c (A C1► S�� g <br /> PHONE (1): "q' `I d S- �441 3 PHONE (2): 2 pq 6 4 - I t s-1 FACSIMILE: <br /> TENTAT/VE*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 125 FEE(CAS OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List ❑ Map- Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# _ Street Name City 1/7 ❑Unit 1 <br /> 21. 2 12- .1/ C�}L1 �.-✓1c S ToCkTaN R1 <br /> C N A )4)Ti„,- L,/Ay —('6 C- o Al ❑ Unit 2 <br /> 3. <br /> 4. nit 3 i� <br /> 5. �� <br /> 6. unit 4 <br /> 7. <br /> 8. ❑ Unit 5 <br /> 9. <br /> 10. ❑ Unit 6 <br /> Specific Date Range of Information Requested: From to y+_� <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES ``���J r <br /> ❑6p6ERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYIVEHICLE `\ / <br /> F] ER CLEANUP SITE(NON-LOP) F1 Fool)FACILITY ❑WASTE TIRE \A <br /> �/j i ^A\ <br /> ❑.I�NDERGROUND TANK(MONITORINGIREMOVAL),V F-1DOGKENNEL ❑DAIRY V" � 1 <br /> L ARDOUS WASTE GENERATORjY F-1CHICKENRANCH ❑WASTEWATER TREATMENT PLANT o' <br /> FLI IERED PERMITTED FACILITYrx- ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TATTOO/BODY PIERCING ❑POOUSPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑COMPLAINT RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(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•mm d•ately.av 'able for ar��ev'p. A new applic tor2 may f,b <br /> submitted when the file is available. I()IV/)` : U1-i( ZZ//}�I J �� ,f r'o' , �) Y Owas rete Is�d �be reor nl Vd` sta t X bfi h�) v� lic nt.4. Any file not returned in the same condition a g $ P Pp <br /> Future file reviews by the same applicant may require a$125 deposit rior to review. 10,Zp <br /> crtS, 14f-I-) EHD USE ONLY 5 � » �j -� G r <br /> f r <br /> ff <br /> 3 at -co 41 <br /> in <br /> -I .-I I' - It i LI 5 a- L6 (pt <br /> EHD 48.06Cj 10(9 G-,lj;hI6#1`6)' 3;.1�.C�Q���iCL U�1hLPi #S t'A ISI5e 0y BI H1 <br />