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DATE RECEIVED EHD LOG NUMBER <br />Al <br />�� E <br />Il�� -�„ � SAN JOAQUIN COUNTY <br />u ENViitONMENTAL HEALTH DEPARTMENT <br />3 f <br />7 <br />AUG 1 1 2009 600 East Main St. Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Tax: (209) 464-0138 Web: www.sjgov.org/el i <br />ENV! OW.1EN F HEALTH <br />PERS+,IT/SERVIGE3 PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: Lei of {moiP c BUSINESS/AGENCY: <br />ADDRESS: CITY/STATE/ZIP �(►°o,-j CA - 4?S3(o <br />PHONE (1): 20 4 — $9 9 " 21 c7 p PHONE (2): <br />ACSIMILE: <br />TENTATIVE* APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application submittal - *Tentative only - must be confirmed) <br />0 CHECK BOX TO EXPEDITE REQUEST - $115.00 FEE (C OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE <br />Electronic Information: ❑ List ❑ Map - Description: <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />FILE ADDRESS <br />EHD USE ONLY <br />OTHER CLEANUP SITE (NON -LOP) <br />Street # <br />Street Name <br />- 72_Sr.cTt° <br />��fDS6iJ't DRIB 5TOr-KToN AuE <br />City <br />I-, pN, CA <br />❑ Unit 1 <br />1 • <br />0 HAZARDOUS WASTE GENERATORO"�,, <br />2, <br />Cl WASTEWATER TREATMENT PLANT <br />ffivD SFS oit/� sr,P,cr iV WE$ <br />0 MOTEL/HOTEL <br />❑ Unit 2 <br />a <br />Unit 3 <br />.� <br />6�4 "a <br />3. <br />❑ POOL/SPA <br />2 3 S. STn CK ►n S3', <br />- <br />11 MEDICAL WASTE FACILITY <br />4. <br />5. <br />Unit 4 <br />6. <br />- <br />7. <br />❑ Unit 5 <br />8. <br />_ <br />9. <br />❑ Unit 6 <br />10. <br />Specific Date Range of Information Requested: From <br />to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />11 HOUSING ABATEMENT <br />13 SOLID WASTE FACILITYNEHICLE <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />❑ WASTE TIRE <br />UNDERGROUND TANK (MONITORING/REMOVAL) I^ <br />❑ DOG KENNEL <br />0 DAIRY <br />0 HAZARDOUS WASTE GENERATORO"�,, <br />11 CHICKEN RANCH <br />Cl WASTEWATER TREATMENT PLANT <br />O TIERED PERMITTED FACILITY OL <br />0 MOTEL/HOTEL <br />0 PUMPER TRUCK/YARD/CHEM TOILETS <br />❑ TATTOO/BODY PIERCING <br />❑ POOL/SPA <br />171 LAND USE APPLICATION SITES <br />11 MEDICAL WASTE FACILITY <br />13 OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW - MONDAY -FRIDAY 8:00 AM-5:00PM - 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 (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 $115.00 deposit prior to review. <br />EHD USE ONLY <br />***If you need further assistance <br />please contact Diane Martinez @ (209)468-3425 directly. Thank You*** <br />2 u <br />Ocl' c v <br />EHD 48.06 8/01/2009 <br />