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` EHD LOG PLUMBER D97CM rE ''iV i�SAN JOAQUIN COUNTY LSU li(71 i ENVIRONMENTAL HEALTH DEPARTMENT JAN 2 2 2004 304 E Weber Ave 3rd Floor Stockton, CA 95205 11 (209) 458-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd ENVIRONMENT HEALTH PERMIT/SERVICES Ij PUBLIC RECORDS RELEASE APPLICATION 1fuH1G� aT-� BUSINESSIAGENCY: 1✓' A r' cp 5ooe) c APPLICANT �I ADDRESS: `"5u-�. '� W ILX0Q W 67 ,. ,WaQt\j 952,05 PHONE FACSIMILE: M .465'_ ~� ! TENTATIVE* APPOINTMENT DATE: YY F'c • .,> LLj /! _-M( life; ? i (Please allow 10 business days from date of application subm -MME COPY l CHECK BOX TO EXPEDITE RET - 3.00 FE REQUEST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OF APPLICANT � DATE p 23 4C� I ii I� Department Use Only u UNIT Unit 2 F1 Unit 3 �_Dq ❑ Unit 4 Cd'r) El Unit 5 to. street �? +a I j Ij ! ENVIRONMENTAL HEALTH DEPARTMENT FILES UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS TATTootBODY PIERCING I� ❑ POOLISPA ❑. LAND U APPLI PEON IT S MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECI [--y ! v List up to ten addresses in the space above. Select the type(s) of files from the list above py checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-09.38 or mail to the address indicated above. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately five business days but no later than ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. !; A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a $93.00 deposit prior to review. *TENTATIVE appointment dates must be confirmed with EHD staff. Applications received after 3:00 pm will be processed the next business day. CONFIRMED APPOINTMENT DATE TIME DATE CONFIRMED PHONE FAX INITIALS REVIEWED YES NO REVIEW DATE EHD 4a-02-006 91IV2003 II q FILE ADDRESS 1. Street lrj� 2. Street 3. Street -- 4. Street_. S. Street oty 6. Street r cAty 7m street ip city B. Street aty 9. Street " cityty u UNIT Unit 2 F1 Unit 3 �_Dq ❑ Unit 4 Cd'r) El Unit 5 to. street �? +a I j Ij ! ENVIRONMENTAL HEALTH DEPARTMENT FILES UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS TATTootBODY PIERCING I� ❑ POOLISPA ❑. LAND U APPLI PEON IT S MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECI [--y ! v List up to ten addresses in the space above. Select the type(s) of files from the list above py checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-09.38 or mail to the address indicated above. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately five business days but no later than ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. !; A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a $93.00 deposit prior to review. *TENTATIVE appointment dates must be confirmed with EHD staff. Applications received after 3:00 pm will be processed the next business day. CONFIRMED APPOINTMENT DATE TIME DATE CONFIRMED PHONE FAX INITIALS REVIEWED YES NO REVIEW DATE EHD 4a-02-006 91IV2003 II