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11/04/2011 14:33 8A 80 PEM PAGE 01/01 <br /> RECEIVED <br /> DATE a1-rFIVFn SAN .IDAQUIN COSLI <br /> o P y EHD LOG NUMBER <br /> U ® 201 ENVIRONMENTAL HEALTH DEPARTMENT <br /> ENVIRONMENTAL HEALTH 600 East Main St. Stockton, CA 95202-3029 <br /> PERMIT/SERVICES <br /> AL ES Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATI N . r <br /> r <br /> APPLICANT: ` m1//✓� BUSINESS/AGENCY: ha C4, <br /> ADDRE5S:roo /STATE/ZIP: <br /> PHONE(1): `fps' °'��7 0 PHONE(2): FACSIMILE f �3"v <br /> T TATVE*APPOINTMENT DATE: Time; <br /> (Please allow 10 buaine»days f to of applioation rubor 1 •Tontstivo only-muet bo confirmod) <br /> ❑CHECK 80X TO EXPEDITE REQUES - C l' 0 <br /> O C NLY)-REQUEST PROCESSED IN 3 BUSIN S D S <br /> SIGNATURE OF APPLICANT DATE l <br /> Electronic Information: ❑List❑ ap-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street Street Na o J- city Unit 1 <br /> 2. `L r! ..CiY1P %..1��`� D "ZUnit2 <br /> 4. 67 <br /> Q <br /> 2b I <br /> 6. /11 �. - I'J Unit._......, . - 4 <br /> 7. L rqql_J(` <br /> $" l- ❑Unit <br /> all I <br /> i <br /> 1 o. Vfi t nit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HoUSINO ABATEMENT tl.10 WASTE FACILITYIVEHIC <br /> THER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY STE TIRE <br /> NDERGROUNDTANK(MONn'on1NWREMOVAL) ❑Doc KGNNIiL iRv <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> �'IERED PERMITTED FACILITY [�MOTELIHOTEL UMPER TRUCKIYARDICHEMICAL TOILETS <br /> TATTuOIBODY PIERCING ❑POOLISPA LAND USE APPLICATION SITED <br /> ❑ MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY B:00 AmZ:DOPNI(EXCLUDING HOLIDAYS) <br /> 1. List un to ten addressg.F,,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 typo MUST be selected. Fax to(209)464-0138 or mail o Lha address indicated above. Address <br /> ranges will not be acGapted-for addltional aeoiatance with filo addronnea,contact the EHD. Appliontlons 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 flies will be held for a maximum of five 1lusinvrss tlayo fvr review. Appuinlments <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 s me applicant may require a$122 deposit prior to review. <br /> ;AD v-T� EH0USE ONLY <br /> loale <br /> - <br /> I � <br /> EHD 4"6 m>2lina <br />