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0 111 11", --ed GeoEnvIro�mentaI � � � 0 9 P. 1 <br /> D)�t��� F '� >. EHD P. dUMBER <br /> v D SAN JOAQUTN COUNTY- �j r �? <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SEP - 1 2005 304 East Weber Avenue, 3'd Floor, Stockton, CA 95202-2708 <br /> ENVIRONMENT HEALTf lephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION 1q717 <br /> APPLICANT: �SuZar\hg 9,QW On BUSINESS/AGENCY: >1 V% wj <br /> ADDRESS: 0 Q STV `7 <br /> PHONE( Q PHONE(2): d�Q I / FACSIMILE,c:� 7 ` —1112, <br /> L <br /> TATIVE'APPOINTMENT DATE: 9d.LTime: <br /> (Please allow 10 business days from dale of application submittal-'Tentative only-must be confirmed) ,- <br /> CHECK BOX TO EXPEDITE QUE T-593.00 FEE(CAS CHEC NLY)-REQUEST PROCESSED IN1,113U IN S DAYS <br /> SIGNATURE OF APPLICANT DATE Q <br /> UNIT DISTRIBUTION ❑ Unit 1 Unit 2 ❑ Unit 3 ❑ Unit 4 ❑ Unit 5 ❑ Unit 6 ❑ Other(electronic/llsts/maps) <br /> FILE ADDRESS EHD USE ONLY <br /> Street# reet N me City <br /> �. aAl V <br /> z. <br /> 3. <br /> 4. a <br /> �. c <br /> Ilk <br /> 6. <br /> 7. oa c <br /> (7 'let C O C <br /> 9. <br /> 10. <br /> Specific Date Range of Information Requested: From <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING A13ATEIMENT ❑SOLID WASTE FACILITYIVEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> UNDERGROUND TANK(MON ITORINGIREMOYAL) ❑DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMIMI)FACIU'rY ❑MOTEUHOTEL ❑ UMPER TRUCKNARDICHEM TOILETS <br /> ❑TAT-roo DY PIERCING ❑POOLISPA I AND USE APPLICATION SITES <br /> ❑MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECK / ~ <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW- MONDAY-FRIDAY 5:00 AM-6:00PM - EXCLUDING,HOLIDAYS, <br /> 1. List up to ten addressee in the space above. Select the type(s)of files from the list above by checking the <br /> appropriate box(es). At least one file type MUST be selected. Fax to(2091464-0138 or mail to the address <br /> Indicated above. Address ranges will not be accepted—for additional assistance with file addresses,contact <br /> the EHD.Applications received after 3:00 pm will be processed the next business day. <br /> 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> approximately ten (10)days after receipt of application. The files will be held for a maximum of five business <br /> days for review. Appointments 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 <br /> application may be 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 <br /> applicant. F=uture file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> P <br /> EHD 49.02-006 <br /> 1114106 <br />