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DATE RECEIVED EHD LOG NUMBER <br />RECEIVED, <br />E SAN JOAQUIN COUNTY Q & <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />JAN 0 9 2013 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />ENVIRONMENTAL HEALTH 1\* <br />PERMITISERVICES PUBLIC RECORDS RELEASE APPLICATION <br />_- <br />APPLICANT: BUSINESS/AGENCY: <br />�;�\�`.� � ��vr <br />ADDRESS: ' 1) I -L S . C, ,(j P_,y-,^I` ti c F • CITY/STATE/ZIP: <br />PHONE (1): �_� �— (, -7—IM PHONE (2): FACSIMILE: <br />TENTATIVE* APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application submittal - *Tentative only - must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST - $125 F (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICAN----DATE <br />Electronic Information: ❑ List ❑ Map — Description: <br />FILE ADDRESS EHD USE ONLY <br />Street # Street Name City ❑ Unit 1 <br />L, 2. ❑ Unit 2 <br />3. <br />S II? <br />dunit 3 <br />4. <br />5. <br />/ <br />P Unit 4 <br />6. <br />9.lig : 11� <br />01 <br />10.MW nit 6 <br />Spe ific Date Range of Information Requested: From to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY SOLID WASTE FACILITY EHICL <br />❑ HER CLEANUP SITE (NON -LOP) ,,,�pp ❑ HOUSING ABATEMENT ❑ WASTE TIRE K t ra { C ��- ✓fG� <br />OTHER <br />TANK (MONITORING/REMOVAL) 9k - ❑ FOOD FACILITY ❑AIRY ---3, '-. <br />ABOVEGROUND TANK 0�— ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER TREATMENT PLANT <br />AZARDOUSWASTEIHAZARDOUS MATERIALS ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEMICAL TOILETS <br />RED PERMITTED FACILITY �%`,r, ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br />TATTOO/BODY PIERCING ❑ COMPLAINT/RESPONSE 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. ***BOXED AREA - EHD USE ONLY* <br />*� <br />1 ❑ Records provided by Staff -PPR Complete. Staff Name: <br />