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/18/2006 10:59 FAX 1a002/002 <br />DATE RECEIVED SAN Qunv COUNTY EHD LOC NUMBER <br />`� <br />r� E � � � V E Nv><RONMENTAL <br />HEALTH DEPARTMENT <br />11"1 ' East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />reQepbone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />ENVIRONMENT HEALTH <br />PFRMIT/SERVITUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: LIS BUSINESSIAGENCY: <br />ADDRESS. 2 — C'rffY__ �TO -Ti / STATE, T <br />PHONE (1) �q ��� I `IS` PHONE (2): FACSIMILE_ <br />TENTATIVE" APPOINTMENT DATE: _ / L �� (v Tlme: I Z <br />(Please allow 10 business days from date of application submttW-`Tentat/ve only - must be confirmed) <br />© CHECK BOX TO EXPEDITE REQ UE T -;93.04 FEE (' SH OR CHECK ONLY) - REQUEST PROCESSED IN 9 DUSINE.`iS DAYS <br />�j SIGNATURE OF APPLICANT DATE I I T d5d�— <br />`' <br />c <br />Information <br />{nforrnatlon <br />Q Llst ❑Map -Description <br />SOM WASTE FACILITYNEHICLE <br />Street t <br />FILE ADDRESS <br />street Name <br />EHD USE ONLY' <br />city <br />1' <br />�' <br />DAIRY <br />❑ Unit 1 <br />2. <br />- <br />L ! <br />11 TIERED PERMITTED FACIUTY <br />❑ MOTEIHOTEL <br />1 <br />P I co <br />; ,.. ,� <br />� Unit 2 <br />4. �i <br />1 <br />� <br />WELL AND SEPTIC PERIM RECORDS ARE AVAILAALE FOR REVIEW - MONDAY -FRIDAY 8:00 AM-5:00PM - EXCLUDING HOLIDAYS. <br />s. <br />Unit 3 <br />6. <br />7. <br />Unit 4 <br />. <br />8. <br />s <br />❑ Unit 5 <br />10. <br />Unit 6 <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />L7 HOUSING ABATEMENT <br />SOM WASTE FACILITYNEHICLE <br />OTHER CLEANUP Sr1E (NON -LOP) <br />O FOOD FACUTY <br />❑ WASTE TIRE <br />CKUNDERGROUND TANK (MONITORING/REMOYAQ <br />0 DOG KENNEL <br />DAIRY <br />illi HAZARDOUS WASTE GENERATOR <br />d CHICKEN RANCH <br />'PXASTEWATFR TREATMENT" PLANT <br />11 TIERED PERMITTED FACIUTY <br />❑ MOTEIHOTEL <br />❑ PUMPER TRUCKIYARDICIIEMICAL TOILETS <br />❑ TATTOOIBODY PIERCING <br />ID PDOLISPALAND <br />USE APPLICArom Snzs <br />0 MEDICAL WAsTE FACILITY <br />0 OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERIM RECORDS ARE AVAILAALE 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 checl,Jng the <br />appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the zlddress <br />Indicated above. Address ranges will not be accepted —for additional assistance with file addresses, contact <br />the EHD. Applications received after 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 <br />approximately ten (10) days after receipt of application. The files will be held for a maximum of five business <br />days for review. Appointments 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 <br />application may be 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 expanse of the <br />applicanL Future file reviews by the same applicant may require a $93.00 deposit prior to review. <br />END 4" <br />10131r2009 <br />