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VO/4M I.1 Vtt 44 <br /> "TT EH0 LOG NUMB <br /> SAN JOAQUIN COUNTY <br /> ENVIRQNMi=NTAL Hr=AI_T�1-1 DEPARTMENT <br /> 600 East Main St: Stockton,' CA 95202-3029 <br /> Telephone' (209)468-3420 Fax: (209)4641-0138 Web: www.sjgov.orglehd <br /> EI'��rli�Qaltn�i.�TAL�G�I_ Ii PUBLIC RECOR17:3 RELEASE APPCICA7ION <br /> APPLfCANT: �(� ����� EUSIHMrSSIAGf�NCY:�1R5fi�C7P�'1 t. ����57A� <br /> PHONE(1): q 6 j--&'4Q0.`Y-r 1.0 PHONE(2):_�� J fid_ �Q _ FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please scow 10 buMnese days from date of aolaff tion submittal-*Tentativ6 only-must be eonflrmed} <br /> ❑CHECK BOX TO EXPEDITE REQU T-S't22 FEE(CASH OR CHECK QNLYj-REQUEST P.ROCE55>=0 IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANTDATE <br /> Electronic Information: ❑ List Map--DescriptiOdRM t�1.3 - C2tia_N[1 STC7fPcG "C� KS _ <br /> FILE ADDRESS, EKED USE ONLY <br /> Strom# 3treel Nam® City ❑Unit 1 <br /> fi_F <br /> �alc� - !�7r ©Unit 2 <br /> 3. 1533 - LiIAb_<A Sr <br /> 4 <br /> W f(_So t� W Pr <br /> 5. 446 hl VN I LSO .Vj r4 /Jl <br /> ti <br /> 6. nit 4 <br /> 7. <br /> 8. 0 Unit 5 <br /> 9. <br /> 10. El Units � <br /> Specific Date Range of Information Requested' From y. _ to �S <br /> ENVIPONMENTAL HEALTH DEPARTMENT-MILES [ <br /> KUNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HoosiNG AsATEIAFNT ❑SOLID WASTE FACILITYNEHICLE <br /> ❑OTHER CLEANUP SITE(NoN-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORINGIRFMOVAL) ❑EIGG KENNEL: ❑DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑C-HICKEN RANCV! []WASTEWATER TREATMI NT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MoTELIHOTEL' LlPUMPER TRucK1YArtD/CHEMICALTOILETS <br /> ❑TATTOO130DY PIERCING Q POOLISPA El LAND USE APPLICATION SITFS <br /> F_] MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) 7 <br /> WELL AND SEPTIC PERMiX RECORDS ARE AVAtLABLE.FOR REVIEW: MONDAY-FRiOAY 8:00 AM-5:00PMI(EXCLUDING HOUDAYS) <br /> 1. List up to ten addresses In the spate 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_LUM 464-0112or mail to the address indicated ebova. Address <br /> ranges will not be accepted-for additional assistance With filo 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 FHD 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- Afile 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 hot returned in the same condition as released will be Peorganized by EHD staff at the expanse of the applicant. <br /> Futuro file reviews by the same applicant may require a$122 deposit prior to review. <br /> EHD USE ONLY <br /> EHU 40-05- D7@BTO <br />