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DATE R � e /C EHD LOG NUMBER �/ L SAN JOAQUIN COUNTY JUN 0 2 2011 ENVIRONMENTAL HEALTH DEPARTMENT Ob 600 East Main St. Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ENVIRONMENTAL HEALTH PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION APPLICANT: yes ,� s7 BUSINESS/AGENCY: (� � ADDRESS: . CITY/STATE/ZIP: 5-"4- PHONE (1): PHONE (2): FACSIMILE: ;j 3 •--7/7 TENTATIVE*APPOINTMENT DATE: Time: (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) ❑ CHECK BOX TO EXPEDITE REQUE 122 FE H OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OF APPLICANT DATE - � Electronic Information: ❑ List ❑ Map-Description: _ FILE ADDRESS EHD USE ONLY Street# Street Name CityT_ t� ❑ Unit 1 ——2. � � # �l Unit2 A 3. 3� ✓`rct 4. —. -- ----- ---, Unit 3 5. �I� 6. Unit 4 7. 8. ❑ Unit 5- 9. 1 10. ❑ unit 6 Specific Date Range of Information Requested: From to ENVIRONMENTAL HEALTH DEPARTMENT FILES 'k'15El �f UNDERGROUND TANK(UST)CLEANUP SITE(LOP) HOUSING AB ❑ATEMENT SOLID WASTE FACILITYIVEHICLE 3 f C OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE UNDERGROUND TANK(MONITORINGIREMOVAL) ❑DOG KENNEL ❑DAIRY HAZARDOUS WASTE GENERATOR( ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANK I ❑TIERED PERMITTED FACILITY ❑MOTELIHOTEL /� 1 ❑PUMPER TRUCKIYARDICHEMICAL TOfCETS ❑TATTOOMODY PIERCING ❑POOL/SPA ❑LAND USE APPLICATION SITES ❑ MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM (EXCLUDING HOLIDAYS) 1. List up to ten addresses in the space above. Select the type(s)of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the address indicated above. Address ranges will not be accepted-for additional assistance with file addresses,contact the EHD. Applications received after 3:00 pm will be processed the next business day. 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a$122 deposit prior to review. EHD USE ONLY - l = - ll1 I (,,7i i I Lo- EHD EHD 48-06 ��