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DATE RECEIVED A 6"1 rvUmntK <br />� SAN JOAQUIN COUNTY `J <br /> ENVIRONMENTAL HEALTH DEPARTM T <br /> 304 East Weber Avenue, 3 `d Floor, Stockton, CA 95202-2708 <br /> Telepho3RECORDS <br /> ) 468-3420 Fax: (209) 464-0138 Web : www.sjgov.org/ehd <br /> 2005APRP6 AM10ITPURELEASE APPLICATION <br /> 14 APPLICANT: R / - BUSINESS/AGENCY: - EN .VIR ON DENT AL <br /> r t <br /> /l ADDRESS : , / 4tI ! <br /> . /tPHONE (1 ): T77 * PHONE (2): D/— df3.2 to FACSIMILE: <br /> TENTATIVE" APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of a lication submittal - ` Tenfative only - must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQjZ32 F ASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 US ESS DAYS <br /> SIGNATURE OF APPLICANT, DATE j2C t7 � <br /> UNIT DISTRIBUTION ❑ Unit 'l If ❑ Unit 2 ❑ Unit 3 ❑ Unit 4 ❑ Unit 5 ❑ Unit 6 ❑ Other (electronic/lists/maps) <br /> FILE ADDRESS END USE ONLY <br /> Street # Street Name City <br /> 1 : DO9 / r4 tx7M 3 Q <br /> 3. <br /> 4, <br /> 5. <br /> 6. <br /> 7. <br /> 8. <br /> 10. <br /> Specific Date Range of Information Requested : From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> DERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITYNEHICLE <br /> THEIR CLEANUP SITE (NON-LOP) 13FOOD FACILITY ❑ WASTE TIRE <br /> UNDERGROUND TANK (MONITORING/REMOVAL) _ ❑ DOG KENNEL ❑ DAIRY <br /> L7 HAZARDOUS WASTE GENERATOR - ❑ CHICKEN RANCH ❑ WASTEWATER TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEUHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOO/BODY PIERCING ❑ POOL/SPA ❑ 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:OOPM - 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 <br /> appropriate box(es). At least one file type MUST be selected . Fax to (209) 464-0138 or mail to the address <br /> indicated above. Address ranges will not be accepted — for additional assistance with file addresses, contact <br /> the EHD. Applications received after 3 : 00 pm will be processed the next business day. <br /> 2. The END will notify the applicant if any END files exist. An appointment for review will be confirmed <br /> approximately ten (10) days after receipt of application. The files will be held for a maximum of five business <br /> days for review. Appointments should be scheduled accordingly. <br /> 3. A file that is actively being worked on by END staff may not be immediately available for review. A new <br /> application may be 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 <br /> applicant. Future file reviews by the same applicant may require a $93.00 deposit prior to review. <br /> EHD 4e-02-006 <br />