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O:t 1?. 20 10:4�F,l APITA <br />No. 0330 P. 2 <br />EHD LOG NUMBER <br />DATE RECEIVED SAN JOAQUIN COUNTY <br />RECEIVED ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main St. Stockton, CA 95202-3029 <br />OCT 14 2011 Telephone: (209) 468-3420 Fax: (209) 464.0138 Web: www.sjgov.org/ehd <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: HUSINESSIAGENCY: An+, -4q (;YL) P <br />ADDRESS: 312- pt Y[tw M20ad CITY/STATFJZIP: ba.✓L�oScr GE '16130 <br />PHONE(1): (rt02o ar2Ir-1077 PHONE (2): FACSIMILE:) 2,2-5-' 13So� <br />TENTATIVE`APPOINTMENT DATE:NOJGrnt t✓ 3 a" Time: fn ooa <br />(Please allow 10 business days from dale of application submittal -•Tentative only -must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST -$125 FEE GASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE__LO <br />Electronic Information: ❑ List ❑ M - Description: <br />ht'fkr beer- AS -Mrs 90 <br />FILE ADDRESS <br />EHD USE ONLY <br />t 1 <br />ENVIRONMENTAL HEALTH DEPARTMENTTILES <br />PNDERGROUNO TANK (UST) CLEANUP SITE (LOP) E] HOUSING ABATEMENT <br />Street k <br />Street Nam <br />City <br />❑ Fool) FACILITY <br />F-1 DOG <br />❑ WASTE TIRE <br />❑DAIRY <br />s�� <br />N <br />NOERGROUND TANK(MONITORINGIREMOVAL)D< <br />I "42 <br />2• <br />- -'I t/� -- <br />��. -.�i Lo{(S JGni1� <br />7C� Yn <br />3• <br />35 <br />E ScottsAVLv1 <br />o <br />0 .- LI <br />Unit 3 <br />4. <br />] TATTOolllov PIERCING <br />❑ POOLISPA - <br />NAND USE APPLICATION SITES <br />5. <br />] MEDICAL WASTE FACILITY <br />❑COMPLAINT RECORDS <br />p OTHER (PLEASE SPECIFY) <br />4114 <br />S•_ <br />T. <br />ung 6 <br />8• <br />9. <br />nit s <br />10, <br />Spaclfle. bale Range of Information Roquaslod: From <br />ht'fkr beer- AS -Mrs 90 <br />to i9dy lite r "N'' <br />ENVIRONMENTAL HEALTH DEPARTMENTTILES <br />PNDERGROUNO TANK (UST) CLEANUP SITE (LOP) E] HOUSING ABATEMENT <br />�/ <br />(�J SOLID WASTE FACHlTYNEHICLE <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ Fool) FACILITY <br />F-1 DOG <br />❑ WASTE TIRE <br />❑DAIRY <br />s�� <br />N <br />NOERGROUND TANK(MONITORINGIREMOVAL)D< <br />KENNEL <br />llft <br />I,WASTE GENERATOR <br />FT <br />[__1 CHICKEN RANCH <br />[I WASTEWATER TREATMENT PLANT <br />v' <br />TERED PERMITTED FACILITY O< <br />❑MOTELIHOTEL <br />❑ PUMPER TRUCKIYARDICHEMICAL TOILETS)O� <br />] TATTOolllov PIERCING <br />❑ POOLISPA - <br />NAND USE APPLICATION SITES <br />] MEDICAL WASTE FACILITY <br />❑COMPLAINT RECORDS <br />p OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:ODPM (EXCLUDING HOLIDAYS <br />1. List u0 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. rax to 2091 464.0136 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 flies exist. An appointment for review will be confirmed approximately ten (10) <br />days ager receipt of application. The flies will be held for a maximum of five business days for review. Appointments <br />should be scheduled accordingly. <br />3. A rile 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 $125 deposit prior to review. <br />