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06/.19/2010 08 :34 FAX 61685291,.Z., Geocon Cons ltants �001/00 <br /> BATE R EHD LOG NUMDER <br /> SAN .JOAQUIN C LINTY <br /> _0 ENVIRONMENTAL HEALTIj DEPARTMENT <br /> V 600 East Main St. Stockton, A 95202-3029 <br /> p tln (209) 468-3420 Fax: (209) 464- 138 Web, www.sjgov,org!5hO5 <br /> PUBLIC RECORD <br /> S RELEASE APPLICATION <br /> �C pp <br /> AWPUlCANT: tCka e2pot4 tj - BUSINESS/AGENCY: EL-'>C.gh! •�,.,-r <br /> (;ADDRESS: C7 C1TYlSTATEIZIP: ,�p CAPA �( , <br /> PHONE(i):Q(�) Ssz��1( 8 PHONE(2).0-D + FACSIMILE: _q( =clm t <br /> TENTATIVE*APPOINTMENT DATE; Time: I iota <br /> (Please allow 10 business days from date of application sub lttal-'Tentative only-must be eonflnned) <br /> CHECK BOX TO EXPEDITE REQUEST-$122 FEE(CASH OR CHECKONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIG ATURE OF APPLICANT DAT(; <br /> Electronic Information: ❑ List❑Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Strest IF Street Name CI Unit 1 <br /> 1. <br /> 2. &C)o <br /> nit2 <br /> <.. <br /> a. 2,3 I S ��� U <br /> r. <br /> 19 <br /> I� <br /> Units <br /> IIS .clf`W1D&4kng V f o- Requested: From to <br /> ENVIRONMENTAI,HEALTH DEP RTMENT FILES <br /> IUNDERGROUND TANK(UST)CLEANUP SITE(LOP) HOUSING AeATEM ENT SOLID WASTE FACT <br /> OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY WASTETIRE '` '� <br /> UNDERGROUND TANK(MONITORINGIREMBVAL) ❑DOG KENNEL DAIRY a} x <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH WA$TEWATER TREATMENT PLANT �Wj <br /> TIERED PERMITTED FACILITY []MOTELIHOTEL PUMPER TRVC.K(YARDICHEMICAL TOILETS <br /> TATTOO/Boj)y PIERCING ❑POOL/SPA LAND USE APPLICATION SITES <br /> K MEDICAL WASTE FACILITY Q OTHER(PLEASE SPECIFY) <br /> ,d WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MO DAY-FRIDAY 8:00 AM-6:00PM EXCLUDING HOLIDAYS} <br /> '11. LM u to ten addreMg,5 In the space above. Select the type(s)of film from the list above by Checking the appropriate <br /> box(es). At least one file type MUST be Selected. Fa 9 464-n 35 or mall to the add s,Indicated ab vg. Address <br /> ranges will not be accepted-for additional assistance with file addresses,contactthe 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 file$exist. An appointiT ant for review will be confirmed approximately tan(10) <br /> days after receipt of application. The files will be held for a maxlrnui rt of five buslness 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 Immi diataly available for review. A new application may be <br /> submitted when the Nle Is available. <br /> .4. Any file not returned In the some condition as released will be reorganized by EHD staff at tha f the applicant <br /> Future file reviews by the same applicant may require a$122 depositprior to review. <br /> eMo 119e ONLY <br /> Klh y' <br /> kHl?48-08 07129!10 <br />