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04/25/2013 11:53 3232654006 ENVIRONMENTAL .a ETY PAGE 01/01 <br />_ � Q� EHD LOG NUMBER <br />DATE <br />EIVED <br />"- QUIN OUNTY <br />ENVIRONMENTAL EAL EPA T ENT <br />APR1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />T?Wphone: (209) 458-3420 Fax' (209) 464-0138 Web: www.sigov.org/ehd <br />ENYH ONMENTIALl EA!TOU LIC RECORDS RELEASE APPLICATION <br />_ . PEWIT/ <br />BUSINESSIAGENCY: <br />APPLICANT: U�tYI <br />ADDRESS: '21ti 101 CITY/STATE/ZIP: CID <br />PHONE (1): 3a -7,Z1 -1371-- - ---- PHONE (2): 5Z3-�C��i .��.�1 FACSIMILIE=: 6,�2. <br />TENTATIVE" APPOINTMENT DATE: 'f Time: ' <br />(Please allow 10 business days from dafe of app cation submittal -'Tentative only- must ba confirmed) <br />❑ CHECK BOX TO EXPEDITE REQU EST - FE (CASH OR CHECK ONLY) . REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE u1 11 <br />rElectronic Information: ® List ❑ Map— Desc`iiption: 1 <br />Specific Date Rsoge of InfofmaUon Requested: From I to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LAP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE FACIL IVEHI LE <br />® OTHER CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT ❑ WASTE TIRE '?, - <br />® UNDERGROUND TANK (MONITORINGIREMOVAL ❑ FOOD FACILITY []DAIRY j . l `� <br />❑ ABOVEGROUND TANK ❑ CHICKEN RANCH/ DOG KENNEL [j WASTEWATER TREATM 44PLANT <br />❑ HAZARDOUS WASTE/HAZARDOUS MATERIALS ❑ MOTELIHOTEL ❑ PUMPERTRUCKIYARDICHEMICAL TOILETS <br />❑ TIERED PERMITTED FACILITY ❑ POOUSPA ❑ LAND USE APPLICATION WES <br />❑ TATTooBODY PIERCING ❑ COMPLAINTIRESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY FRIDAY 8:00 AM-6:00PM (EXCLUDING HOLIDAYS) <br />1. List uo 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 (200) 4640138 or, mall 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 ®m will be processed the next business day. <br />