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P E 1V <br /> �w••�+ EHD LOG NUMBER <br /> RD� SAN .10AQUIN COUNTY <br /> OCT 2 6 2016 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> EWROW.E.WTAL Rft"hone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> i"E.F3WMERVI .Lc& - <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESS/AGENCY: ok �q,06k f'C_� )Nb- <br /> ADDRESS: D 32-CITYISTATE/ZIP:'�DSfNl\.1I� , 1150(v <br /> PHONE(1): �tV PHONE(2): FAX OR E-MAIL: Y(.�( \(? �O�VIL(O�QIS�O*I& <br /> Please al ow 10 business days from date of application submittal for the records to be available. •t,�YV1 <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑CHECK BOX TO EXPEDITE T-$13 H HECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List Map–Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City <br /> WN � ; <br /> 6)? Ci <br /> ? Un;t 2 <br /> 4 o n� E]Unit 2H <br /> {� nit 3 <br /> JL_ <br /> 6. <br /> 7 ❑Unit 4 <br /> $ SITE MITIGATION <br /> 9• R Unit 5 <br /> 10. <br /> Specific Date Range of Information Requested: From ALL to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> VUNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MOTELIHOTEL SOLID WASTE FACiLITYNEHICLE <br /> 50THER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT FOOD FACILITY <br /> 9 UNDERGROUND TANK(MONITORINGIREMOVAL) ❑WASTE TIRE ❑DAIRY,POOLISPA <br /> ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> [HAZARDOUS <br /> AZARDOUS WASTE ❑MEDICAL WASTE FACILITY ❑PUMPER TRUCK/YARD/CHEMICAL TOILETS <br /> MATERIALS ❑TATTOOIBODY PIERCING ❑LAND USE APPLICATION SITES <br /> IERED PERMITTED FACILITY ❑COMPLAINT/RESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(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.Applications received after 3:00 pm will be processed the next business day. <br /> 2. For assistance in identifying the nature and content of EHD records,please contact EHD at the number noted above. <br /> 3. 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 /> 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$130 deposit prior to review. <br /> "*BOXED AREA-EHD USE ONLY— <br /> , 2 <br /> 0 000 i�'� <br /> 0 Records provided by Staff-PPR Complete. 3taff Name: Ill Poll,i <br />