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DATE RECEIVER EHD LOG NUMBER <br />• SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main St. Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.org/ehd <br />r <br />t <br />a <br />� • 1-50 rte. �L+• � �` rri.0 r. A '? <br />PHONE (1): <br />PHONE (2): <br />FACSIMILE: <br />TENTATIVE* APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application subrrdttal . •Tenfadve 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 <br />Electronic Infonnation: ❑ List ❑ Map — Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />Unit 1 <br />Street 0 <br />Street Name <br />city <br />1. <br />A95'i10 <br />❑ Unit <br />2. <br />3. <br />Unit 3 <br />4. <br />❑ Unit 4 <br />S• <br />7. <br />❑ Unit 6 <br />8• <br />9. <br />❑ Unit 6 <br />10. <br />Specific Date Range of Information Requested: From [7" �—lb _ _ _ _ to g 3p -IrS <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />❑ UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITYNEHICLE <br />❑ OTHER CLEANUP SITE (NON -LOP) ❑ Foy FACIUTY ❑ WASTE TIRE <br />❑ UNDERGROUND TANK (MDNrFORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br />❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ WASTEWATER TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEMICAL TOILETS <br />❑ TATTOO/BODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY P OTHER (PLEASE SPECIFY) C®M-3,2(Sq <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REviEw: MONDAY -FRIDAY 8:0 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 Ole type MUST be selected. Fax to 1209) 464-0138 or mail to the address indicated above. Address <br />ranges will not be accepted - for additional assistance with Ole 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 />