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DATE RECEIVED 0 SAN .IOAQUIN COUNTY®/ 0 EHD LOG NUMBER <br /> RECEIVED <br /> �( G ENVIRONMENTAL HEALTH DEPARTMENT <br /> JAW 31 2017600 East Main St. Stockton, CA 95202.3029 I _ <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: wvvw.sjgov.org/ehd <br /> E <br /> NTALHEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> PERMITIS II /� C <br /> APPLICANT: q I BUSINESSIAGENCY: `J �',Cp_En U.l r on n,(nim I <br /> ADDRESS: '?Mf) W I S1 i r[; POW *_2"D 10 CITY/STATE/ZIP: �bS {y nUC IP.1 <br /> PHONE(1): '.13-I)S()-Qi)g0 PHONE(2): FACSIMILE-�I3' D'©�Dri <br /> TENTATIVE"APPOINTMENT DATE: Time. <br /> (Please allow 10 business days from date of application submittal-'TentaOva only-must be confirmed) <br /> ❑CHECK BOX TO EXPEDITE REQUEST $1 FEE H OR CHECK ONLY)-REQUEST PROCESSED IN 3 BU INESS DAYS <br /> SIGNATURE OF APPLICANT _Z' �, /w DATE� ./'31��C71? <br /> Electronic Information: ❑ List❑Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> street If Street Name City ❑unit 1 <br /> 1. �{ 27611, <br /> 2. <br /> nit 2 <br /> 4. /O <br /> Unit 3 <br /> Pv. (fna" <br /> 6. C b —fT—Unit 4 <br /> T. <br /> 8• ❑Unit 5 <br /> 9. <br /> 10. mt <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT SOLID WASTE FACIUTYNEHICLE <br /> THER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY WASTETIRE <br /> NDERGROUND TANK(MONToRWGIREMOVAL) ❑DOG KENNEL '-�❑DAIRY <br /> AZARDOUS WASTE GENERATOR Q CHICKEN RANCH WASTEWAYERTREATMENT PLANT <br /> nnnIII------III TIERED PERMITTED FACILITY ❑MOTELIHOTEL PUMPER TRUCKIYAROICHEMICAL TOILETS <br /> �TATroo/BODY PIERCING ❑POOLISPA ❑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 types)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 mall to the address indlCated 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 ayailable 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$122 deposit prior to review. <br /> ENO USE ONLY <br /> EHO 48-0e 07129/10 <br />