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L)ATEjjE=VEL, �' EHD LOG ilUP.4BER SAN �OAQUIN COUNTY EI ,;ONMENTAL HEALTH DEPARTtA OCT 2 8 2011 600 East Main St. Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (20 - 8 .sjgov.org/ehd ENVIRONMENTAL HEALTIi � PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION APPLICANT: �y�� y Sn. l-Ia BUSINESS/AGENCY: ADDRESS: Q �SiIP Tr� CITY/STATE/ZIP: PHONE (1): -,�2d 92_ PHONE (2): FACSIMILE: TENTAT/VE*APPOINTMENT DATE: Time: (Please allow 10 business days from date of application submittal -'Tentative only - must be confirmed) ❑ CHECK BOX TO EXPEDITE REQUEST - $125 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OF APPLICANT DATE Electronic Information: ❑ List ❑ Map - Description: - 2.'- UNDERGROUND TANK (UST) CLEANUP SITE (LOP) FILE ADDRESS Street Name OTHER CLEANUP SITE (NON -LOP) EHD USE ONLY ❑Unit 1 1 Unit 2 Unit 3 nit 4 - - - ❑ Unit 5 Vim' .0/v .•(� Unit Street # City HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH TIERED PERMITTED FACILITY 4. ❑ TATTOOIBODY PIERCING ❑ POOLISPA — - 5. 6. 7. 9. 10. Specific Date Range of Information Requested: From ENVIRONMENTAL HEALTH DEPARTMENT FILES UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ DOG KENNEL HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ TATTOOIBODY PIERCING ❑ POOLISPA ❑ MEDICAL WASTE FACILITY ❑ COMPLAINT RECORDS to ❑ SOLID WASTE FACILITYIVEHICLE ❑ WASTE TIRE ❑ DAIRY ❑ WASTEWATER TREATMENT PLANT ❑ PUMPER TRUCK/YARDICHEMICAL TOILETS ❑ LAND USE APPLICATION SITES ❑ OTHER (PLEASE SPECIFY) WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:00PM (EXCLUDING HOLIDAYS) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address indicated above. Address ranges will not be accepted - for additional assistance with file addresses, contact the EHD. Applications received after 3:00 pm will be processed the next business day. 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately 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. 3. 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. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. u -1v lice reviews oy ure same appncant may require a Giza oeposit prior to review. . I C f:7il b