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F <br /> ;i <br /> T <br /> � <br /> EHD LOG NUMBER <br /> FI rr_�M E DD, SAN JOAQUIN COUNTY <br /> A L5 T 7 40r0 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> ENV1H(llvnri-n; (;:M10`1one: (209)468-3420 Fax: (209)464-0438 Web:wwuv.sjgov.org/ <br /> PERVIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESS/AGENCY: 4e�fUtrrn <br /> ADDRESS: c�q 1 [� • Q, LO p CITYISTATE011P.- St C&,rM orf �[ <br /> PHONE(1): PHONE(2): ,; FACSIMILE:gog — <br /> TENTATIVE*APPOINTMENT BATE: $1�7 j f v i M Time; o v <br /> (Please allow 10 business days from data of application submittal•- entaWe only-must be confirmed) <br /> ❑CHECK BOX 70 EXPEDITE REQUEST- 1 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED 1N 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT r DATE <br /> 1r-7 Ila <br /> Electronic Information, ❑List❑Map—Description:' <br /> FILE ADDRESS EHD USE ONLY <br /> Street Stmet Nems City Unit 1 <br /> 1. ct4S ,] <br /> {3 Unit 2 <br /> 3. <br /> 4. <br /> �g Unk 3 <br /> S. {' <br /> nit 4 <br /> r. <br /> ' n Unit S <br /> 9. <br /> 10. <br /> (�units <br /> Specific Data Range of information Requested: From c] S 7C tp t�Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES { <br /> ❑UNOEROROUNO TANTS(UST)CLEANUP$ITE(LOP) ❑HOUSING ABATEMENT ❑Soul)WASTE FAGILITYIVEHICi-E <br /> ❑OTHER CLEANUP SrrE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> ❑UNDEROROUND TANK(MONITORINGIREMOYAL) ❑DOG KENNET. ❑DAiRY <br /> ❑HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATmEtiT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTELMOTEL ❑PUMPERTRUCKIYARoICHEMICAL.TOILETS <br /> ❑TATrM/El0DY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SrrEs <br /> ❑ MEDICAL WASTE FACILITY WOTHER(PLEASE SPECIFY) p 6roS C .jb S 0],Iof' <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAil-APIFOR REVIEW: MONDAY-FRIDAY$:00 ANS 0M(EXCLUDING I'IOLIDAYS) <br /> 1. List u to ten a sses in the space above. Select the type(s)of files from the listali'ove by checking the appropriate <br /> box(as). At least one file type MUST be selected. Fax to( 0l)4s"in or mall W the'addres0 indicated ghove. Address <br /> ranges will not be accepted-for additional asalstance 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 flies 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 available 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 /> enouerGNLv <br /> 3f <br /> EHD 43-0e 47129/10 <br />