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03/02/2011 12 : 05 FAX [6001/001 <br /> SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> htCENED <br /> ENVIRONMENTAL HEALTH DEPARTMENT 6d��-MAR U 2 2011 600 East Main St. Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> 2ERMIT/SEM ICES <br /> APPLICANT:_0,�,� j}"�..LJAy, BUSINESS/AGENCY: e4laca1> <br /> ADDRESS: y`�y 1Mker_0f'kt k4c CITY/STATE/ZIP: S&C,ZAM&�rb tc_ -J587 1 <br /> PHONE(1): C416� q3o -OV-1 PHONE(2);(gf0&%jq-ZS 12 FACSIMILE:(!_el g807�*0� <br /> TENTATIVE`APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-•Tentsdve only-must be confirmed) <br /> [] CHECK BOX TO EXPEDITE REQUES $122 FE ASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE V- <br /> 7-Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street 0 Street Name City ❑Unit 1 <br /> 1. to0o Sn~4415TTI �.rtf1� <br /> _ t <br /> 2. ZJd1� SA+k(„jt►4irTT } � ❑Unit2 <br /> 3. oo SA A(,V1 N44F-M C_A ric 35 a <br /> 4. -ru b 5T6W014e_T %T&_kTVN Unns I <br /> 6• Unit 4 {L' <br /> 7. <br /> 8. El Unit 3 <br /> 9 + <br /> 10. p Unit ti <br /> Spaclflc Date Range of Information Requested: from to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑DOG KENNEL ❑DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTELIHOTEL ❑PUMPER TRUCKNARD/CHEMICAL TOILET$ <br /> ❑TATtOOIBODY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS <br /> 1. List up to ten addresses in the space above. Select the type(s)of files from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(209)4134-013§or mail to the address indicated above. Address <br /> ranges will not be accepted-for additional assistance 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 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. 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 EHO staff at the expense of the applicant. <br /> Future file reviews by the same applicant may require a$122 deposit prior to review. <br /> EHD USE ONLY <br /> EHp 4S-0s 072aho <br />