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-a EHD LOG NUMBER <br /> DF�TE;REGEIVED 4' <br /> SAN.10AQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> lU� i 2411) 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> APPLICATION <br /> APPLICANT: kP- file t1A W0_11W BUSINESSIAGENCY:' AE/ Cay f~tT (NtJ <br /> ADDRESS: a/9I Ae ,r/ZAcGL /dL✓0 9226 CITY/STATE/ZIP: T24C } <br /> PHONE (1): q)_S-- L/q7–T.t y3 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�U/EST-$126 FEE(CASp OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT /c. �JIDATE731//3 <br /> Electronic Information: ❑ List❑ Map–Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name _ ,;.M, city ❑Unit 1 <br /> 1. 3 Y o t •f.3 ,� G/6rJ e S/ory /a R�/ -s{,�/��,, <br /> Od- <br /> 2•' i(Pvj /_p o— l3 ❑Unit e <br /> 3• <br /> I/ 4. nit3 �3J <br /> llt��Vii 5. ���� <br /> 6. P t c t fA td'Unit4 <br /> 7. <br /> 8. ❑Units <br /> 9. <br /> 10. ❑Unit <br /> Specific Date Range of Information Requested: From jQ L L to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ®UNDERGROUNDTANK(UST)CLEANUP SITE(LOP) ❑MEDICALWASTE FACILITY ❑SOLID WASTE FACm YNEHjCUELI. __ .y <br /> ©OTHER CLEANUP SITE(NON-LOP) [-IHOUSINGABATEMENT ❑WASTETIRE f(I{aj 311`/` �• <br /> UNDERGROUND TANK(MONITORINGIREMOVAL)- ❑FOOD FACILITY E]DAIRY oa,8, (Z-f3 <br /> ABOvEGROUNDTANKI�- ❑CHICKEN RANCHI DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOUSWASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPERTRUCKIYARDICHEMICALTOILEfs <br /> ®TIERED PERMITTED FAcIL9*7111 ❑POOUSPA ❑LAND USE APPLICATION SITES <br /> ❑TATTODIBODY PIERCING ❑COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELLAND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-6:00PM(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(1.0) <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$126 deposit prior to review_ *"BOXED AREA-EHD USE ONLY"" <br /> 7c5�'- s Yom' <br /> odah <br /> '13 ,Nv i <br /> vj M(414pi <br /> ErReeerds-prbvlded-by-Steffi F`"e fete.Stff Name: <br /> EHD 48-06 914112 <br />