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DATE RECEIVED ENi► KONMENTAL HEALTH DEPARTMWENT OCT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ; , ,VIRONMENTALHEALTH PUBLIC RECO PERMIPSERVIC58 aqo�• 'ci man y APPLICANT: BUSINESSIAGENCY: EHD LOG NUMBER ADDRESS: 1�--��-S CITY/STATE/ZIP: PHONE (1): ) C)Gj —)A --I -1�,�Z PHONE (2): ZD FACSIMILE: TENTATIVE* APPOINTMENT DATE: Time: (Please allow 10 business days from date of application submittal - *Tentative only - must be confirmed) ❑ CHECK BOX TO EXPEDITE REQUEST - ".FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS SIGNATURE'OF APPLICANT 7A" I Electronic Information: ❑ List ❑ Map — Description: 1 FILE ADDRESS EHD USE ONLY S ific Dat 'Range of Information Requested: From L0 ENVIRONMENTAL HEALTH DEPARTMENT FILES ROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE, AN'.1k!5 ICLEr H CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT ❑ WASTE TIRE //``,,//,, N ERGROUND TANK (MONITORINGIREMOVAL) QC. ❑ FOOD FACILITY ❑ DAIRY lim %�- )Qd 7i�i I Z OVEGROUND TANK ( ❑ CHICKEN RANCHI DOG KENNEL ❑ WASTEWATER TREATMENT PLANT AZARDOUSWASTE/HAZARDOUS MATERIALS� ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEMICAL TOILETS 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 files 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 END staff at the expense of the applicant. Future file reviews by the same applicant may require a $125 deposit prior to review. BQXE -A A - EHD U 0 1 EHD 48-06 Street # Street Name City ❑Unit 1 � 6'r S� ` S'Fo�Y1 r ` ► a, ❑ Unit 2 2. ""❑ Unit 3 4. 5. "nit 4 g. 7. ❑ Unit 5 8. 9. ❑ Unit 6 10 S ific Dat 'Range of Information Requested: From L0 ENVIRONMENTAL HEALTH DEPARTMENT FILES ROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE, AN'.1k!5 ICLEr H CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT ❑ WASTE TIRE //``,,//,, N ERGROUND TANK (MONITORINGIREMOVAL) QC. ❑ FOOD FACILITY ❑ DAIRY lim %�- )Qd 7i�i I Z OVEGROUND TANK ( ❑ CHICKEN RANCHI DOG KENNEL ❑ WASTEWATER TREATMENT PLANT AZARDOUSWASTE/HAZARDOUS MATERIALS� ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEMICAL TOILETS 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 files 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 END staff at the expense of the applicant. Future file reviews by the same applicant may require a $125 deposit prior to review. BQXE -A A - EHD U 0 1 EHD 48-06