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s <br /> o � � 4+ miL,_r• iC <br /> FfV F3IQ�KIE �-- � 488 260 8627 � Mar. 28 2B11EeD:LONGRNUMBER <br /> DATE <br /> ED <br /> ri'1,9� � 2U11 SAN JOAC2UIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ENVIRONMENTAL HE600 East Main St. Stockton; CA 95202-3029 <br /> PERMIT/SERVICE$ phone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINES5/AGENCY:_ <br /> ADDRESS: '�.(� ��� CITY/STATE/ZIP: c�� �!��� <br /> PHONE (1): PHONE(2) FACSIMILE: �2(coA00 <br /> TENTATIVE'APPOINTM NT DATE: FVl :t Time: 11 �10 W C')oo <br /> P/ <br /> (Please allow 10 business days from date of application submittal-"Tentative only-must be confirmed) <br /> UV CHECK BOX TO EXPEDITE REQUEST-9122 FEE(CASH OR CHECK ONLY)'REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT ( /,) (�( ! ;t - DATE Wa4 <br /> Electronic Information: ErList❑ Map—Description: <br /> FILE ADDRESS EHO USE ONLY <br /> Street 0 Street Name city i Unit t <br /> 2 <br /> _, ..._ ❑Unit 2 <br /> 4. <br /> 4 N <br /> And 3 <br /> s. 1 <br /> B- 0 Unit 5 <br /> 9- <br /> 10. r.... <br /> ` Unit s <br /> Specific Date Range of Information Requested: Fromto kA <br /> ENVIRONMENTAL HEIAL H D P RT T F ,,`` <br /> Log DERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT E� LID WASTE FACILITYIVEHICUF <br /> MOTHER CLEANUP SITE(HON-LOP) - ElFOOD FACILITY ❑WASTE TIRE <br /> LyQUNDERGROUND TANK(MONRORINUREMOVAL) ❑DOG KENNEL ❑DAIRY <br /> V DOUS WASTE GENERATOR ❑CHICKEN RANCH ❑.WASTEWATER TREATMENT PLANT <br /> IER$D PERMITTED FACILITY ❑MOTELIHOTEL '' - ❑PUMPER TRUCKIYARD/CHEMICAL TOILETS <br /> ❑TATTOO/BODY PIERCING ❑POOL/SPA ❑LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY -- ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 Am-5:00pm(ExCLUDING HOLIDAYS) <br /> t. List up to ten addresses in the space above. Select the fype(s)of files from the list above by checking the appropriate . <br /> box(es). At least one file type MUST be selected. Fax to(20Q)464-0138 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 Tiles 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$122 deposit prior to review. <br /> EHD USEONLY <br />