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DATE RECEIVED EHD LOG NUMBER <br />0 SAN JOA COUNTY <br />ENVIRONMENTAL HEALTH DEPARf4ENT <br />600 East Main St. Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.org/ehd <br />APPLICANT: I I &w e'sS ot l.. A V✓ BUSINESS/AGENCY: S F IPQ_ <br />ADDRESS: U eSS CITY/STATE/ZIP S <br />PHONE (1): [�_ a PHONE (2): FACSIMILE: <br />TENTATIVE* APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application submittal - *Tentative only - must be confirmed) <br />CHECK BOX TO EXPEDITE REQ��ST - $105.00 FEE (CASH OR CHECK ONLY) -REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT /d(bU10 DATE LZ b <br />Electronic Information: ❑ List ❑ Map — Description: <br />FILE ADDRESS EHD USE ONLY <br />Street # Street Name City ❑ Unit 1 <br />2 ❑ Unit 2 <br />3. <br />❑ Unit 3 <br />4. <br />5. ❑ Unit 4 <br />6. <br />7. <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 />E3 UNDERGROUND TANK (UST) CLEANUP SITE (LOP) 13 HOUSING ABATEMENT 13 SOLID WASTE FACILITYNEHICLE <br />13 OTHER CLEANUP SITE (NON -LOP) E3 FOOD FACILITY ❑ WASTE TIRE <br />13 UNDERGROUND TANK (MONITORINGIREMOVAL) O DOG KENNEL 13 DAIRY <br />13 HAZARDOUS WASTE GENERATOR O CHICKEN RANCH ❑ WASTEWATER TREATMENT PLANT <br />® TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br />❑ TATToo1BODY PIERCING ® POOL/SPA 13 LAND USE APPLICATION SITES <br />13 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) 464-0138 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 EHD staff at the expense of the applicant. <br />Future file reviews by the same applicant may require a $105.00 deposit prior to review. <br />***If you need further assistance please contact Diane Martinez @ (209)468-3425 directly. Thank You*** <br />EHD 48-06 8/04/2008 <br />