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DATE RECEIVED - J EHD LOG NUMBER <br /> RECEIVED ENVIRONMENTAL <br /> JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SEP 0 3 2015 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> E-WRONMENTALHEALTH PUB"""LIC RECORDS RELEASE APPLICATION <br /> APPLICANT: A— J� 6/1/if•�7 BUSINESS/AGENCY: AlJTM <br /> ADDRESS: 1165t) C-Jtf0E/j(Xk Qp SS 1/d/r k,!Cffd fu2lbut dSF70 CITY/STATEIZIP: GF14 Ch-YtW4 C-4 <br /> PHONE(1): g�D 3��7 aI3 Pt1fl 1)� nld - !k10.)IU I GAC IMh` 6 631E y X1' <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑CHECK BOX TO EXPEDITE REQUEST- 0 E (CAv/ <br /> SH OR CHECK ONLY)-REQUEST PROCESSED IN 33 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE —3—2,&/S <br /> Electronic Information: ❑List❑ Map—Description: <br /> FILE ADDRESS <br /> n street# Street Name ' city EHD USE ONLY <br /> 1• F1 r r� e l>9y S1ac u�� cO,c1,eN -Loth <br /> 2. <br /> ❑unit 1 <br /> 3. <br /> ❑Unit 2 <br /> 4. Fr4e C <br /> L"SBtf"�: [I Unit 2H <br /> 8- et'g-1 f/unit 3 <br /> 7. <br /> 9/unit 4 <br /> 8. <br /> ❑SITE MITIGATION <br /> 9. <br /> Ila. <br /> ❑Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTHiDEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYIVEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ❑HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPERTRUCKiYAROICHEMICALTOILETS <br /> ❑TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOO/BODY PIERCING ❑COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM.5:80PM(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. i <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. ***BOXED AREA-EHD USE ONLY"* <br /> tl. <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 49-06 <br /> 711716 <br />