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DATE RECEIVED SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> DECEIVE® ENVIAMENTAL HEALTH DEPARTMA <br /> 600 East Main St, Stockton. CA 95202-3029 <br /> JAN q 3N)Whone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> V <br /> ENVIRONMENTAL HEALTH <br /> PERMITISERVICES P IC RECO DS RELEASE APPLICATION <br /> APPLICANBUSINESS/AGENCY: <br /> ADDRESS: 91 �_}5 /) tt- 151_ji4__3 CITY/STATE/ZIP: wpo Cat Ij33U <br /> PHONE (1): ZOy) (gQ'} -IGty\ PHONE (2): FACSIMILE: <br /> TE WIVE*APPOINTMEN TE: Time: <br /> (Please allow 10 busine s day fro ofF <br /> a ' submittal-'Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE OUEST- 12 E of \R,C\H LY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List❑ Map- Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name Zots' City ❑ Unit 1 <br /> - <br /> 6. <br /> 2. <br /> ❑ Unit 2 <br /> -- <br /> 4. <br /> Unit 3 / <br /> 5. <br /> aNri gzZ`t 1'L_ ,`Unit4 <br /> 7. <br /> 8. <br /> - Unit <br /> 5 <br /> 9. <br /> 10. <br /> ❑ Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> NDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT ❑SOLID WASTE FACILITYIVEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL ❑DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TATTOO/BODY PIERCING ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY [P-COMPLAINT RECORDS ❑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(2091464-0138 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 $125 deposit prior to review. <br /> Ei 10 USE ONLY <br /> EHD 48-06 811111 <br />