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D T i5 SAN JOAQUIN COUNTY EHD LOG NUMBER <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />EAfVIIiQFiMailf4l. FiEA- <br />elephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd Oq7(.P) <br />PERMITl�WCE6"' PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: \vV kLTI;'E� KN CL.t- N BUSINESS/AGENCY: mit"e >L ✓• <br />ADDRESS: p. b:,X- -7(-3( W] CITY/STATE/ZIP: S t��CAR 2, c57a <br />PHONE (1): b4 -7'S -JPS S `6,( � PHONE (2): FAX OR E-MAIL: W 0, 1kr-0. ei1Cttl Ger V. <br />Please allow 10 business days from date of application submittal for the records to be available. <br />Staff will contact you to arrange an appointment date and time to review the requested records. <br />❑!CHECK BOXTO'EXPEDITE REQUEST, $139 FEEi(CASH-ORICHECK ONLY)-IREQUESTIRROCESSED,IN 3'BUSINESS DAYS <br />SIGNATURE OF APPLICANT �� ��� DATE �0 (.*(t (D <br />1. List up to ten addresses in the ce below. Select the type(s) of files from the list below by checking thb ap ropriate <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. Applications received after 3:00 pm will be processed the next business day. <br />2. For assistance in identifying the nature and content of EHD records, please contact EHD at the number noted above. <br />3. 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 />4. Any file not retumed 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 $139 deposit prior to review. <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:OOPM (EXCLUDING HOLIDAYS) <br />Electronic Information: ❑ List ❑ Map - Description: <br />Specific Date Range of Information Requested: From A Lc— to -- <br />ENVIRONMENTAL <br />IHEALTH DEPARTMENT <br />FILE ADDRESS <br />EHD USE ONLY <br />(FILES <br />UNDERGROUND TANK (UST) <br />Street # <br />Street Name <br />city <br />1 <br />�, <br />( <br />CLEANUP SITE (LOP)CONSUMER <br />�QTHER CLEANUP SITE (NON -LOP) <br />5' v <br />` <br />KI 'HAZARDOUS WASTE <br />TIERED PERMITTED FACILITY <br />I SCJ <br />(Ll�; a.�, <br />s � <br />[IR <br />DAIRY <br />-{'j�,,V^'V /f/��`L ^IJ kill <br />�' �'v /C, <br />BOVEGROUNO TANK <br />11 /7�l ill/C <br />-UST (MONRORING I REMOVAL)^\ <br />w1 <br />❑ PWS <br />HAZARDOUS MATERIALS <br />XS PILLIRELEASE RESPONSE <br />, <br />WAi cR QuA!ITv <br />SOLID WASTE FACILITY I VEHICLE <br />FOOD FACILITY <br />POOL / SPA <br />SITE MITIGATION <br />DAIRY <br />5 <br />v O V <br />LAND USE APPLICATION SITES <br />C] HousING <br />SEPTIC PUMPER TRUCK / <br />YARD / CHEMICAL TOILETS <br />6 <br />❑ WASTEWATER TREATMENT PLANT <br />CUPA <br />HOUSING ABATEMENT <br />MOTEL/HOTEL <br />❑ CHICKEN RANCH I DOG KENNEL <br />"'PA - UST <br />❑ MEDICAL WASTE FACILITY <br />8 <br />TATTOOIBODY PIERCING <br />❑ SCUD WASTE <br />WASTE TIRE <br />COMPLAINT <br />9 <br />OTHER(PLEASE SPECIFY): <br />Ac;ouNnnG <br />10 <br />—BOXED AREA • EHD USE ONLY— <br />