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ttiV LVIi IVVMCtK <br /> I <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> :•ti 1 t 2005 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd J(� <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: AQ60'nZ L2s4/ BUSINESS/AGENCY: 1uj�{ lif' Fu cV Zti.. <br /> ADDRESS: ? I/ <br /> i-3 &_)4 InL /) ,f 0 Fa- �1`6 7-4+ <br /> PHONE(1): '//G ff/ PHONE(2): 6 a ali 7 J _FACSIMILE: <br /> TENTATIVE APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> LI aVVVN/ <br /> rd7 CHECK BOX TO EXPEDITE REQUEST 3.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS �. <br /> SIGNATURE OF APPLICANT Z �� DATE 5_/-//0 <br /> UNIT DISTRIBUTION ❑ Unit 1 ❑ Unit 2 Nunit 3 ❑ Unit 4 ❑ Unit 5 ❑ Unit 6 ❑ Other(electronicllists/maps) <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> 6. <br /> 7. <br /> 8. <br /> 9. <br /> 10. <br /> Specific Date Range of Information Requested: FromAl(. to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑ UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACIUTYNEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑WASTE TIRE <br /> PL UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL Cl DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR C3 CHICKEN RANCH _ ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑TATTOO/BODY PIERCING ❑POOLISPA ❑ 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 <br /> appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the address <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 submittedwhen 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 <br /> applicant. Future file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> EHD M4)2-006 SH <br /> VI V05 <br />