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04/12/2012 12 :45 FAX 2001/001 <br /> DATE RECEIVED <br /> a a e EHD LOG NUMBER <br /> SAN JOAGIIN1J1`' <br /> . CIV ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main St. Stockton, CA 95202-3029 <br /> 12 2012 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: BUS INESS/AGENCY: (y'�P cr1 �(IC,k �I.I L <br /> CITY/STATE/ZIP: Z IADDRESS: 74"3 ✓ <br /> PHONE(1): 141v -023`� PHONE(2): (6 —7,!349 FACSIMILE: (o- !{ 'Ok©3 <br /> TEN TIVE'APPOINTMENT DATE' ( 7 U! L Time: q <br /> (Please allow 10 business days from dat of application submittal-'Tentatfw only-mutt be confirmed) <br /> CHECK BOX TO EXPEDITE REQUEST- 5 FE H OR ECK ONLY)-REDDEST PROGE$$ED IN 3 BUSINESS PAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑List❑ Map—Description: <br /> FILE ADDRESS FMD USE ONLY <br /> Street N Street Name City 1 <br /> 1. �t�OQ COLI U�i� _� <br /> 2. � a - C �t IQ. '" ST S d r�k- <br /> I <br /> 3. AI(Oe <br /> r6. <br /> S• s-� Q q S! S mr . Unit s <br /> pL.(I S• � -A_Pc- S'T S t {` Unit 4 <br /> 8 u Unit 5 <br /> WOW <br /> 9. <br /> 10 13/Unit 8 <br /> 1 <br /> Spectfic Date Range of Information Requested; From _ to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILE8 c,^ <br /> UNDERGROUND TANK(UST)CI.EANUP SITE(LOP) ❑HOUSING ABATEMENT Q SOLID WASTE FAclUTYNEHICLE � <br /> OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY LZy WASTE TIRE (, 7 <br /> NIrORINGIREMOVAL ❑DOG KENNEL ❑DAIRY "^ I��' <br /> UNDERGROUND TANK(MO )L WASTEWATER TREATMENT PLANT /ter <br /> KAIARDOUS WASTE GENERATOk' ❑CHICKEN RANCH ❑ d� ` <br /> TIERED PERMITTED FACILITY g4 ❑MOTELIHOTEL ❑PUMPER E APPLICATION <br /> $rrEs AL TDtLETS <br /> TATTOOIBODY PIERCING ❑POOIISPA E]LAND USE APPLICATION STIES <br /> MEDICAL WASTE FACILITY ❑COMPLAINT RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM•5:00PM EXCLUDING HOUDAYs) <br /> 1. List up to ten addresses in the space above. Select the type($)of files from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. EM to(209)464-0139 or mall tote 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 ton(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. Anew 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 et the expense of the applicant <br /> Future file reviews by the same applicant may require a$125 deposit prior to review, <br /> yj <br /> I <br /> em m <br /> EHD 48.08 <br />