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CY �T/L�Fl�ifi .�i'4d/lf+ ti�li G-ILGLCG � ra't�a'C4vr--ii «ii.-'33.4i.�i.�A ":d�"✓'••t�fi uL F <br /> DATE RECEIVEDqE a 'U <br /> SAN JOAQUIN COUNTY - _ EHD LOG NUMBER - <br /> RECEI ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 *� <br /> JAN 0 9' 201.3 /ehd " <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org <br /> ENVIRONMENTAL HEALTH <br /> PERMITISERVICESPUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: W ' OyAAv r BUSINESS/AGENCY: <br /> ADDRESS: I ) ti q S Cct tJ rte}/W IF rn S CITYISTATE/ZIP: S 17vC_ (e k2'N r Com' <br /> PHONE (1): PHONE (2): FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-`Tentative only-must be confirmed) j <br /> ❑ CHECK BOX-TO EXPEDITE REQUEST-$125 F (CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT'----- — DATE <br /> i <br /> Electronic Information: ❑ List❑ Map-Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street# Street Name City El Unit 1 <br /> 2 ElUnit 2 <br /> 3. /7 <br /> 4. l Unit <br /> 5 <br /> s. <br /> 2 T4s 6at lobe/ `x� I,'3 <br /> 7. <br /> s ❑unit 5 <br /> 9. J <br /> 10, <br /> Ea'Unit6 <br /> spe ific Date Range of information Requested: From to - <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICALWASTE FACILITY ®SOLID WASTE FACILITYIVEHICLE <br /> ❑ HER CLEANUP SITE(NON-LOP) ElHOUSING ABATEMENT E]WASTE TIRE <br /> r ❑AIRY <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ [-]WASTEWATER TREATMENT PLANT <br /> FOOD FACILITY <br /> YABOVEGROUNDTANK ❑CHICKEN RANCHI DOG KENNEL ARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> AZEKED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> TATTOOIBODY.PIERCING ❑COMPLAINTIRESPONSE RECORDS E]OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(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 <br /> 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 A the applicant. <br /> Future file reviews by the same applicant may require a$125 deposit prior to review, ***BOXED AREA-EHD USE ONLY"' <br /> ❑ Records provided by Staff-PPR Cornplete. Staff Name: <br />