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DATE j r.I V C V <br />SAN ..IOAQUIN COUNTY EHD LOG NUMBER <br />MAR 10 2011 ENVIRONMENTAL HEALTH DEPARTME, <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />ENVUj0tWF TALHEAIThfelephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />PERMITISERVICES PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: hLt QUUE' n BUSINESS/AGENCY: <br />ADDRESS: ❑_WjrP WnoA O ir+ CITY/STATE/ZIP: ,SfOa hQn L C & q 5a ) 0 <br />PHONE (1): (`meq) Q(�A- 'If PHONE (2): ' q q� - 5 FAX OR E-MAIL: _��na3pgaa coli' <br />Please allow 10 business days from date Application submittal for the records to be av II le. <br />Staff will contact you to arrange an appointment date and time to review the requested records. <br />❑ CHECK BOX TO EXPEDITE REQUEST - $1P44 <br />(CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT b Cnzi q, 29i DATE Mnjr Iii I sin 1� <br />1. List up to ten addresses in the space below. Select the type(s) of files from the list below by checking the appropriate <br />box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address indicated above Address <br />ranges will not be accepted. Applications received after 3:00 pm will be processed the next business day. <br />2. For assistance in identifying the nature and content of EHD records, please contact EHD at the number noted above. <br />3. 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 />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 $139 deposit prior to review. <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:OOPM (EXCLUDING HOLIDAYS) <br />Electronic Information: ❑ List ❑ Map — Description: <br />Specific Date Range of Information Requested: From igb Q to aOlI- <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FILES <br />FILE ADDRESS <br />�} SE ONLY <br />FL fi <br />®, UNDERGROUND TANK (UST) <br />Street # <br />Street Name <br />CityCO <br />R <br />I T <br />Cher*,,c Ind <br />L <br />�+�CI�"I Qn <br />�/J'{V El CONSUMER <br />`� �r -,,� <br />CLEANUP SITE (LOP) <br />OTHER CLEANUP SITE INON-L P 1 <br />HAZARDOUS WASTE <br />® TIERED PERMITTED FACILI <br />2 <br />DAIRY <br />147 <br />ABOVEGROUND TANK <br />7 <br />/ ❑ PWS <br />/ <br />UST (MONITORING/ REMOVAL) <br />® HAZARDOUS MATERIALS <br />3 <br />® SPILLIRELEASE RESPONSE <br />SOLID WASTE FACILITY /VEHICLE <br />FOOD FACILITY <br />4 <br />WATER QUALITY <br />,1 <br />SITE MITIGATION <br />POOL/SPA <br />DAIRY <br />LAND USE APPLICATION SITES <br />® SEPTIC PUMPER TRUCK/ <br />YARD / CHEMICAL TOILETS <br />5 <br />B <br />f/�� <br />I 1' <br />1\i <br />, <br />HOUSING <br />�l (t <br />WASTEWATER TREATMENT PLANT <br />® HOUSING ABATEMENT <br />MOTFUHOTEL <br />7LZ' <br />^ <br />LAPf CUPA <br />;'�n{���y' <br />-Aw <br />8 <br />CUPA - UST <br />CHICKEN RANCH /DOG KENNEL <br />❑ MEDICAL WASTE FACILITY <br />TATTOO/BODY PIERCING <br />WASTE TIRE <br />® COMPLAINT <br />9 <br />SOLID WASTE <br />® OTHER(PLEASE SPECIFY): <br />T,X'InfoRna},an on <br />'� <br />O�una O w� any to'nS op <br />' e propeffi , <br />❑ ACCOUNTING <br />Y 1 V ru 11 \� , vor t)(QrAli d0e5 t fi —BOXED AREA - EHD USE ONLY` - <br />0 Records provided by Staff -PPR Complete. Staff Name: <br />