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� REG <br />— 11 -.P 20n91336960 i �/ . <br />DA� REoGAv�D ll EHD LOG NUMBER <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH ENVIRONMENTAL HEALTH DEPARTMENT <br />PERMIT/SERVICES 600 East Main St. Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: Qf lei BUSINESSIAGENCY:S� <br />ADDRESS: vrA P e CITY/STATE/ZIP: A rH,A CA._ <br />PHONE (1): ?-} 2 -!qal - P)4i98 P ONE (2): ��� FACSIMILE: - - <br />TENTATIVE* APPOINTMENT DATE: _ Time: 1 M o.Kjn__ <br />(Please allow 10 business days from date of application submittal - "Tentatiye only - must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST - $122 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE <br />Electronic Information: ❑ List ❑ Map - Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />j �} Unit -1— <br />_ <br />to <br /># <br />Street Name <br />City <br />9Street <br />1. <br />❑ HOUSING ABATEMENT <br />} <br />IY�_ <br />Q OTHER CLEANUP SITE (NON -LOP) <br />t j <br />%� ❑ Unit 2 <br />2• <br />- <br />❑ DOG KENNEL <br />❑ DAIRY <br />3. <br />❑ CHICKEN RANCH <br />❑ WASTEWATER TREATMENT PLANT <br />TIERED PERMITTED FACILrro( <br />Unit 3 <br />4• <br />❑ TATTOO/BODY PIERCING <br />❑ POOUSPA <br />❑ LAND USE APPLICATION SITES <br />5. <br />❑ OTHER (PLEASE SPECIFY) <br />nit 4 <br />0 Unit 5- <br />6. <br />7. <br />8. <br />9. <br />El Unit 6 <br />10. <br />_ <br />Specific Date Range of Information Requested! From <br />to <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT FILES <br />® UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />B -SOLID WASTE FACILITYNEHICLE <br />Q OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />❑ WASTE TIRE <br />�] UNDERGROUND TANK (MONITORINGIREMOVAL) t/ <br />❑ DOG KENNEL <br />❑ DAIRY <br />® HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />❑ WASTEWATER TREATMENT PLANT <br />TIERED PERMITTED FACILrro( <br />❑ MOTELIHOTEL <br />❑ PUMPER TRUCK/YARD/CHEMICAL <br />❑ TATTOO/BODY PIERCING <br />❑ POOUSPA <br />❑ LAND USE APPLICATION SITES <br />F1 MEDICAL WASTE FACILITY <br />❑ OTHER (PLEASE SPECIFY) <br />TOILETS <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 $122 deposit prior to review. <br />EHD USE ONLY <br />fI + <br />EHD 48-06 07/29710 <br />