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f EHD LOG NUMBER <br />RECEIVED ��v`� a'" SAN JOAQUIN COUNTY <br />vIRONMENTAL HEALTH DEPARTMENT <br />SEP d 4 Z012 (ftU1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.org/ehd <br />ENVIRONMENTAL HEALTH <br />PERMITISERVICES <br />r <br />APPLICANT: 11 i BUSINESS/AGENCY: ODA, Olh— A rMi <br />ADDRESS: '^t� C'�'Aiy1<') \-De CITY/STATE/ZIP: Zq,663-7 <br />PHONE (1): 6to ?j g1Q��J PHONE (2): FACSIMILE: <br />TENTATIVE* APPOINTMENT DATE: ► Time: kk-0D N -(\- <br />(Please allow 10 business days from date of application submittal - *Tentative only - must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST - $125 FEE <br />SIGNATURE OF APPLICANT <br />Electronic Information: Z List ❑ Map - Descr <br />ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />DATE <br />M <br />FILE ADDRESS I EHD USE ONLY .4 <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT <br />Street # <br />Street Name City Unit 1 <br />1 <br />t rJ <br />lJ�%� '' ! 1 IR/7i 5 <br />❑ Unit 2 <br />2. <br />❑ DAIRY <br />3. <br />❑ CHICKEN RANCH <br />O <br />E] Unit 3 <br />4. <br />❑ MOTELIHOTEL <br />5. <br />❑ TATTOOIBODY PIERCING <br />U Unit 4 <br />6. <br />❑ MEDICAL WASTE FACILITY <br />7. <br />❑ OTHER (PLEASE SPECIFY) <br />P <br />❑ Unit 5 ` <br />8. <br />9. <br />❑ Unit 6 <br />10. <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT <br />❑ SOLID WASTE FACILITYIVEHICLE <br />OTHER CLEANUP SITE (NON -LOP) <br />® FOOD FACILITY <br />❑ WASTE TIRE <br />UNDERGROUND TANK (MONITORINGIREMOVAL) <br />❑ DOG KENNEL <br />❑ DAIRY <br />HAZARDOUS WASTE GENERATOR d"- <br />❑ CHICKEN RANCH <br />❑ WASTEWATER TREATMENT PLANT <br />TIERED PERMITTED FACILITYoe— <br />❑ MOTELIHOTEL <br />❑ PUMPER TRUCKIYARDICHEMICALTOILETS <br />❑ TATTOOIBODY PIERCING <br />❑ POOLISPA <br />❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY <br />® COMPLAINT RECORDS <br />❑ 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) 464-0138 or mail to the address indicated above. Address <br />ranges will not be accepted - for additional assistance with file addresses, contact the END. 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 EHD staff at the expense of the applicant. <br />Future file reviews by the same applicant may require a $125 deposit prior to review. <br />EHD USE ONLY <br />�- -►z�upamal� <br />EHD 46-06 8/1111 <br />