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E EHD LOG NUMBS <br /> p <br /> f IEE SAN JOAQUIN COUNTY <br /> NOV 0 2011 ENVIRONMENTAL HEALTH DEPARTMENT""" �' <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: (rls�ltri �.�rt� BUSINESSIAGENCY: GY1FYcoN tom,1�-- <br /> ADDRESS: 3'13{ yv�evre.,� vt�tu�- <1Z4 C CITYISTATEIZIP: , r�A ft%ZI <br /> PHONE(1): �g(l�� ��` p7 td PHONE(2): ($> Zl- �Q FACSIMILE:�qlb� �{8a- bbn3 <br /> TENNYA�'APPOINTMENT DATE: Time: <br /> (Please allow 10 buslness days from date of application submittal-"Tentefiva only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST 122 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE 10l3t'(r <br /> Electronic Information: [❑ List ❑ Map-Description: <br /> FILE AbDRESS EHD USE ONLY <br /> Street it Street Name City Unit 1 <br /> A6Ina k,,n vke <br /> (IpZ Un it 2 <br /> (f4 <br /> 2$O <br /> lsZg 1 1 �` .. unit 3 <br /> ; �< �U <br /> 6. 0+0 - <br /> itfS; unk 4 <br /> z40. �}�t <br /> Unit 5 <br /> 10. ~ <br /> Unit 6 <br /> Specific Data Range of Information Requxsted: From pit%. to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> [1 DERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING A13ATEMENT [�$pLID WASTE FACILrrYIVEHICLE <br /> LI? E <br /> ER CLEANUP SSPE(NON-LOP) ❑FOOD FACILITY [�—�-�DEM, <br /> v�4+ E TIRE <br /> ERGROUND TANK(MONITORINWREMOVAL) ❑DOG KENNEL YARDOUS WASTE GENERATOR ❑CHICKEN RANCH TEWATER TREATMENT PLANT <br /> IERED PERMfTTED FACILITY M ELIHOTEL ER TRUCKh(ARDICNEMICAL TOILETS <br /> ` ❑TATT00160DY PIERCING L,�PCI PA .AND USE APPLICATION SITES <br /> CN�cN� C�-OEDICALWASTE FACILITY LrJVIHER(PLEASESPECIM Av%-j ",o,-As p covtccrH. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 6:()0.4 �PM(EXCLUDING HOLIDAYS) <br /> 1. List un to ten addresses In the space above. Select the type($)of flies from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(209)464-0136 or mall 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 flies 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 flve 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 retumed 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$122 deposit prior to review. <br /> !HD USE ONLY <br /> EHD"-Ge <br /> OflY9/10 <br /> l00/100XHj EE Zo IIOZ/ZO/ll <br />