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iR � <br />` _FV E D SAN JOAQUIN COUNTY EHD LOG NUMBER <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />MAR2 2011 600 East Main St. Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: vvww.sjgov.org/ehd f <br />ENVIRONMENTAL HEALTH <br />PFRMIT/SIERVICES PUBLIC RECORDS RELEASE APPLICATION <br />( ;/'6 / HJT-�Jr r ,V <br />4l�%i <br />APPLICANT:�BUSIN�EvS C <br />/AGENCY: <br />_der�0.ica.1 t 5�' r t c - <br />ADDRESS: j8,7-77 1V . o w v��,c c� CITY/STATE/7-IP: CA 19525 <br />PHONE (1): Z P 9 • 3,!;V 6-80& PHONE (2): FACSIMILE: ..��• v�9 • l��,Q <br />TENTATIVE" APPOINTMENT DATE: A14,4A 3 /1 Zo /y Time: 205— T6g <br />(Please allow 10 business days from date of application submittal -'Tentative only - must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST - $1,4 FEE (CASH R CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT _ ,�� �� DATE ' Z 2- <br />Electronic Information: ❑ List ❑ Map - Description: <br />to <br />FILE ADDRESS <br />END USE ONLY <br />❑ it 1 <br />- <br />�� <br />aN�D"ERGROUND TANK (UST) CLEANUP SITE (LOP) <br />F - C1 ER CLEANUP SITE (NON -LOP) <br />Street ti <br />Street Name <br />City <br />1. <br />.50 <br />al"t rYtic.� <br />4o ; CA <br />Unit z <br />-- --- - ----- - <br />2.� <br />❑ DAIRY <br />f_._P.'A_t� -L,4,_--El <br />-- <br />3.- <br />[:]WASTEWATER TREATMENT PLANT <br />F] TIERED PERMITTED FACILITY <br />nit 3 _ <br />Unit 4 <br />4. <br />❑ TATTOOMODY PIERCING <br />5. <br />❑ LAND USE APPLICATION SITES <br />-- -------- <br />6. <br />7. <br />8. <br />9. <br />❑ Unit 6 <br />10. <br />Specific Date Range of Information Requested: From <br />to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />fil(✓S �� <br />�� <br />aN�D"ERGROUND TANK (UST) CLEANUP SITE (LOP) <br />F - C1 ER CLEANUP SITE (NON -LOP) <br />HOUSING ABATEMENT <br />[I HOUSING <br />❑ FOOD FACILITY <br />SOLID WASTE FACILITYNEHICLE <br />❑ WASTE TIRE <br />+ <br />urI , <br />I NDERGROUND TANK (MONITORING/REMOVAL <br />❑ DOG KENNEL <br />❑ DAIRY <br />r a rq - (� <br />�AZARDOUS WASTE GENERATOR C\ <br />❑ CHICKEN RANCH <br />[:]WASTEWATER TREATMENT PLANT <br />F] TIERED PERMITTED FACILITY <br />❑ MOTELIHOTEL <br />❑ PUMPER TRUCKNARDICHEMICAL TOILETS <br />❑ TATTOOMODY PIERCING <br />❑ POOL/SPA <br />❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY ❑ 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 $122 deposit prior to review. <br />100 In .LSIQ 9IHH1 S9QRIHO00M C99969£609T XV3 9£:9T T109/99/£0 <br />