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12/12/2012 12:39 5106559517 ENVIRON PAGE 01/01 <br /> ■ <br /> DAIE RECEIVED EHD LOG NUMBER <br /> ■ �,Q SAN �OAQUIN COUNTY <br /> � � ENVIRONMENTAL HEALTH DEPARTMENT <br /> i q <br /> �E� 1868 East Hazelton Avenue, Stockton, CA 95205-623 12 2 <br /> Za) Telephone: (209) 468-3420 Fax: (209)464-0138 Web: vwvw.sjgov.org/ehd <br /> ENVIRONMENTALRMIT/ VCEAI_` PUBLIC RECORDS RELEASE APPLICATION <br /> PERMIT/SERVICES <br /> APPLICANT: BUSINESS/AGENCY: E NV IfLO N <br /> ADDRESS: —x_-i_oL7 (��re�\ S� �2�.� Su P �pb CITY/STATE/ZIP: t-yyjQyt Mp (0 01F, <br /> PHONE (1): PHONE (2): FACSIMILE: Sll�—(aSS'9�i�r <br /> TENTATIVE"APPOINTMENT DATE: OLI..Ag roh-/A cf 'tD Time: <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> ❑CHECK BOX TO EXPEDITE REQUESTj-$125 FEE JCASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List❑ Map—De ription: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City 0 U . 1 <br /> 3�0 5 , g�►��rv�a v, R�1 Lod,i U� T LCW-7 Al <br /> `-�� <br /> 2. <br /> El Unit 2 <br /> 3. <br /> A <br /> 4. AlUnit 3 <br /> 5. — <br /> 6. <br /> EI,Unit 4 ., <br /> 7 o 6 <br /> TO view the HMMP�Hazardous <br /> 8. Materials Management Plan)go to the ❑Unit 5 <br /> g following website:www.sjoesdata.org <br /> 10. <br /> ❑ Unit 6 <br /> Specific Date Range of Information Requested: From cyo-AI,f to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITY/V HIr�. <br /> OTHER CLEANUP SITE(NON-LOP) F1 HOUSING ABATEMENT E]WASTE TIRE 9 I L' I�Yf <br /> UNDERGROUND TANK(MON ITORINGIREMOVAL),,"— ❑FOOD FACILITY ❑DAIRY <br /> ABOVEGROUND TANK 1 ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTEIHAZARDOUS MATERIAL ❑MOTELIHOTEL ❑PUMPER TRUCK/YARDICHEMICAL TOILETS <br /> TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> TATTOOIBODY PIERCING yy��COMPLAINTIRESPONSE 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(209)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 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. *BCE <br /> 13>5X•�7ar�r 'f7i . 1852 <br /> ecelved Time—Dec. 12. `2012—"11 :4YR- o. ta am- -- � - - - — 1_ <br /> E.._ .__.. 9/4112 <br />