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1234 KLEINFELDER 21:12 09-24-2010 1 /1 <br /> DATE RECEIVED EHD LOG NUMBER <br /> \"i E <br /> � SAN �10AQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SEP 2 4 2010 600 East Main St. Stockton, CA 95202-3029 <br /> ENUIRuNIVItNi HEALTH Teleph ne: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> PERMIUMM, PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: _4A� BUSINESS/AGENCY: <br /> ADDRESS: �r4CITY/STATEIZIP: �tx{c�� , <br /> PHONE (1): �� 51 ��3� PHONE(2): �� ��5� � FACSIMILE: -� <br /> TENTATIVE'APP INTMENT DAT <br /> (Please allow 0 business days f date of applic ion submittal,"Tentative only-must be confirmed) <br /> ❑ CHECK SOX TO EXP DITE REQUEST- 12 F E(CASH 0 CHECK O Y)-REQUEST PROCESSED IN 3 BUSINES DAYS <br /> SIGNATURE OF APPLIC NT DATE q 23 a <br /> Electronic Information: List❑Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City <br /> Unit t <br /> Nv S� <br /> V 2. ❑Unit 2 <br /> -3 <br /> 4' - — - <br /> _ _ It 3 <br /> 10 <br /> —6. - - ----- y <br /> nit 4 <br /> 7. <br /> ❑Unit 5 <br /> 9. <br /> 10. <br /> ❑Unit 6 <br /> Specific Date Range of Informatio Requested: From _ to <br /> � ENVIRONMENTAL HEALTH DEPARTMENT FILES j�5 <br /> [ uN RGROUND TANK(UST)CLEA UP SITE(LOP) ElHOUSING ABATEMENT ❑SOLID WASTE FACILITYNEHICLE 3 n <br /> THER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> PA NDERGROUND TANK(MONITORING REMOVALj/\ ❑DOG KENNEL ❑DAIRY <br /> ❑HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTELJHOTEL ❑PUMPER TRUCK/YARD/CHEMICAL TOILETS <br /> ❑TATTOO/BODY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RE ORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List up to ten addresses in t e space above. Select the type(s)of files from the list above by checking the appropriate <br /> box(es). At least one file ty a 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 t e next business day. <br /> 2. The EHD will notify the appli ant If any EHD files exist. An appointment for review will be confirmed approximately ten(10) <br /> days after receipt of applica ion. The files will be held for a maximum of five business days for review. Appointments <br /> should be scheduled actor ingly. <br /> 3. A file that is actively being orked on by EHD staff may not be immediately available for review. A new application may be <br /> submitted when the file is a liable. <br /> 4. Any file not returned in the s me condition as released will be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviews by the sa a applicant may require a$122 deposit prior to review. <br /> EHO USE ONLY <br /> -A-10, ;_ c�� Ki <br /> -21 <br /> 48-06 <br /> 07129170 <br />