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DATE RE EIVED EHD LOG NUMBER BVED SAN JOAQUIN COUNTY E. VIRONMENTAL HEALTH DEPARTMENT MAR 0 4 2013 1868 East Hazelton Avenue, Stockton, CA 95205-6232 -�- Telephone:(209) 468--3420-Fax (209) 464=0138 -Web: Www.sjgov.org/ehd -- ENVIRONMENTAL HEALTH PERMIT(3ERVICES PUBLIC RECORDS RELEASE APPLICATION APPLICANT: BUSINESS/AGENCY ADDRESS 1735- COyA,-TYL7 GLy13 CITY/STATE/ZIP: _ C6UC-7_C/V PHONE (1):' ZO S `�23-_(l �/ PHONE (2):26 f 12S'7 TENTATIVE*APPOINTMENT DATE: FACSIMILE: Time: (Please allow 10 business days from date of application submittal - *Tentative only - must be confirmed) ❑ CHECK BOX TO EXPEDITE REQUEST 4125 SIGNATURE OF APP ONLY) - REQUEST PROCESSED IN 3 BUS NESS DAYS DATEI / 4-1 I "�, Electronic Information: ❑ List ❑ Map` Dbscrip�ion_,�U` - I FILE ADDRESS EHD USE ONLY ENVIRONMENTAL HEALTH DEPARTMENT FILES ❑ UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE FACILITYNEHICLE ❑ OTHER CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT ❑ WASTE TIRE UNDERGROUND TANK (MONITORINGIREMOVAL� r_1 FOOD FACILITY F] DAIRRY f � �j ABOVEGROUND TANK ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER 1 REATMENT PLAN ❑ HAZARDOUS WASTE/HAZARDOUS MATERIALS ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEMICALTOILETS ❑ TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES ❑ TATTOOIBODY PIERCING ❑ COMPLAINTIRESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:00pm (EXCLUDING HOLIDAYS) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by,checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address indicated above Address ranges will not be accepted - for additional assistance with file addresses, contact the EHD. Applications received after 3:00 pm will be processed the next business day. 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) days after receipt of application. The Flies will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. .3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available: 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a $125 deposit prior to review. ***BOXED AREA - EHD USE -ONLY*** � r ON&FAMOTM KIM= r oil 9/4112 Street # Street Name City ❑ Unit 1 1 CAU ,Iwo, MIVA I Lom ❑ Unit 2 .L. 4 3. L® ,�1 Unit 3 4. 5. ❑ Unit 4 6. 7. ❑ Unit 5 8. 9. ❑ Unit 6 10. Specific Date Ranae of Information Reauested: From r., ENVIRONMENTAL HEALTH DEPARTMENT FILES ❑ UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE FACILITYNEHICLE ❑ OTHER CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT ❑ WASTE TIRE UNDERGROUND TANK (MONITORINGIREMOVAL� r_1 FOOD FACILITY F] DAIRRY f � �j ABOVEGROUND TANK ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER 1 REATMENT PLAN ❑ HAZARDOUS WASTE/HAZARDOUS MATERIALS ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEMICALTOILETS ❑ TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES ❑ TATTOOIBODY PIERCING ❑ COMPLAINTIRESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:00pm (EXCLUDING HOLIDAYS) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by,checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address indicated above Address ranges will not be accepted - for additional assistance with file addresses, contact the EHD. Applications received after 3:00 pm will be processed the next business day. 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) days after receipt of application. The Flies will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. .3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available: 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a $125 deposit prior to review. ***BOXED AREA - EHD USE -ONLY*** � r ON&FAMOTM KIM= r oil 9/4112