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tp MA ]LATE RECEIVED SAN JOAQUIN COUNTY ' * ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd EHD LOG NUMBER APPLICANT: 17 j/Nd f MWIiNrBUSINESSIAGENCY: ADDRESS: SZ 6 0 -E-A l L AIVF CITY/STATE/zip: GV' c.4 PHONE (1); - 6elp - TVIPHONE (2): FACSIMILE: 9S".376 TENTATIVE* APPOINTMENT DATE: Time: (Please allow 10 business days from date of application submittal - *Tentative only - must be confirmed) ❑ CHECK BOX TO EXPEDITE REQUES (. OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OF APPLICANT TE . /f• Z'° /Z Electronic Information: ❑ List ❑ Map — Description: I Q %%LW 1A 14NIZ I V FILE ADDRESS I EHD USE ONLY Specific Date Range of Information Requested: From / �' • �` �- to G ENVIRONMENTAL HEALTH DEPARTMENT FILES ❑ UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE FACILITYNEHICLE ❑ OTHER CLEANUP SITE (NON -LOP) ❑ HOUSING ABA ❑ WASTE TIRE ❑ UNDERGROUND TANK (MONTIORIN AL) ❑ FOOD FACILITY ❑ DAIRY ❑ ABovEGRouNo TANK ❑ CHICKEN RANCHI DOG KENNEL ❑ WASTEWATER TREATMENT PLANT ❑ HAZARDMIS WA$TEIHAZARDOUSMATERIALS ❑ MOTELIHOTEL ❑ Pu TRUCKIYARDI ALTOILETS ❑ TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES JZTATTOOIBODY PIERCING ❑ COMPLAINTIRESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:00PM (EXCLUDING HOLIDAYS) 1. List up to ten addresses In the space above. Select the types) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address Indicated above. Address ranges will not be accepted - for additional assistance with file addrewes, contact the EHD. Applications received after 3:00 pm will be processed the next business day. 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the a licant Future file reviews by the same applicant may require a $125 deposit prior to review. Street If Street Name City 0 Unit 1 1. 12. $j4.® A444'(ZA l A -4-t- --119A CA.A ❑ Will: 2 3. Q Unit 3 4. 5. ❑ Unit 4- 6. 7. 0 Unit 5 8. 9. ❑ Unit 6 10. Specific Date Range of Information Requested: From / �' • �` �- to G ENVIRONMENTAL HEALTH DEPARTMENT FILES ❑ UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE FACILITYNEHICLE ❑ OTHER CLEANUP SITE (NON -LOP) ❑ HOUSING ABA ❑ WASTE TIRE ❑ UNDERGROUND TANK (MONTIORIN AL) ❑ FOOD FACILITY ❑ DAIRY ❑ ABovEGRouNo TANK ❑ CHICKEN RANCHI DOG KENNEL ❑ WASTEWATER TREATMENT PLANT ❑ HAZARDMIS WA$TEIHAZARDOUSMATERIALS ❑ MOTELIHOTEL ❑ Pu TRUCKIYARDI ALTOILETS ❑ TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES JZTATTOOIBODY PIERCING ❑ COMPLAINTIRESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:00PM (EXCLUDING HOLIDAYS) 1. List up to ten addresses In the space above. Select the types) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address Indicated above. Address ranges will not be accepted - for additional assistance with file addrewes, contact the EHD. Applications received after 3:00 pm will be processed the next business day. 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the a licant Future file reviews by the same applicant may require a $125 deposit prior to review.