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11/ZU/ZUUU 15/ ID:28 San Joaquin County —> 4640138 2 <br /> ��_ T �iVHpI ' EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> NILIV 2 0 2009 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton,01 8 Web:www.sigov.org/e <br /> EfVViRttlVi;?tl�iT;-�E�,LTTflephone: (209)468.3420 Fax: (209)464.0138 Web:wwwsjgov.orgle J <br /> PERV,I1;'SERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: _DEAR/r> BUSINESSIAGENCY: A.5 e,6,p_ _ <br /> ADDRESS: 44- N . s� r,. L a �n CITYISTATE2IP: s�z,<.xroN C,/i 1?51Poa <br /> PHONE(1): (,2o9) PHONE(2): FACSIMILE: (�o'I) q44-53 7:5 <br /> TENTATIVE'APPOINTMENT DATE: DI=c 4 aoo9 Time: Iy:« <br /> (Please allow 10 business days from date of appllca Ion submittal-'Tentedve only-must be confirmed) <br /> ❑CHECK BOX TO EXPEDITE REQI�I�'�ST-$115 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT RED <br /> _e DATE_No Jq .2yny <br /> Electronic Information: ❑List❑ Map—Descriptlon: <br /> FILE ADDRESS EHD USE ONLY <br /> Street If Street Name A PN City y1`1 h ❑Unit 1 <br /> 1' 7o Col IrP, CLQ / <br /> 2. al3A 6. YIA9IPv3A AD, 173-oto 15 'o L3(0 \ <br /> 3' a44. ern. SPA" N 045 ./76-I Lool 5.t QG5rA1JIJ,(A1 <br /> C. HW 0111. O-6 Loe..KCFodO Unita <br /> 5• 3s N. H@."OKEC LN -n' Loo Ul sr No <br /> 8. UI K " ' :mRN Oar-I 0-1 L(1 I _ ) nit <br /> T, <br /> 8. <br /> ❑Unit 5 <br /> 9. <br /> 10. <br /> ❑Unit e <br /> Specific Data Range of Information Requested: FromII n to !' LIPRLNt- <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES / G <br /> ®UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FAOILITYNEHICLE <br /> ®OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTETIRE JJ <br /> ®UNDERGROUND TANK(MONITORINGIREMOVAL) ❑DOG KENNEL ❑DAIRY U'*?(I <br /> Ia HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑MOTELIHOTELI / <br /> W/BODY PIERCING ❑PUMPER TRUCKICARON SITES LTOILETS <br /> TArT <br /> ❑PWUSPA ❑LAND USE APPLICATION SITES <br /> ❑MEDICAL WASTE FACILITY ❑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 un to ten addresses in the space above. Select the types)of files from the list above by cfte0 Ing 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(Ilea exist, An appointment for review will be confirmed approximately ten(10) <br /> days after receipt of application, The files will be held fora 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 deposit prior to review. <br /> 6. If you need further assistance,please contact Diane Martinez,at(209)460.3426. <br /> EMU USE ONLY <br /> -O <br /> END 1a-0E i a (A <br />