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CL: ::.;ai —.,,�:L:: ....... :v _ ...� ____�_, , . --------------------- EHD LOG NUMBER <br />DATr1�E [Z 9 V E.—L- P SAN JOAQUIN COU14TY <br />ENVIRONMENTAL HEALTH DEPART MENT <br />JUN 0 . 20115 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: vvww.sjgov.org/ehd �• <br />R06 1If.Ei [A1_ HEALTHPUBLIC RECORDS RELEASE APPLECAT€aN <br />ffPLICANT: C�la�iT�F I��ft%1l�ll BUSINESS/AGENCY: CJ'y✓,jry f�✓�:,�G <br />t1DRESS: ('�"�� I G�j'•Ij 14 <br />CITY/STATE/ZIP:�G`rl <br />r� B� FAX OR E-NPtAIL: C -i (<; j <br />PH0NtE (i): �„ il�,� �i C�' (. -.s> , , { PHONE (2): <br />Please alloy 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 - $130 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT v� �'���'��� DATE <br />1. List up to ten addresses in the space below. Seiectthe type(s) of flies from the list below 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 cond°flan 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 $1310 deposit prior to review. <br />kYELL AND SEPTIC PERI�11IT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:00PM (EXCLUDING HOLIDAYS) <br />Electronic Information: ❑ List ❑ Map — Description: <br />SnPrific Date Range of Information Requested: From to <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FILE ADDRESSD <br />UI5N. <br />�� � �E 0 � ��" <br />FILES <br />UNDERGROUND TANK (UST) <br />Street # <br />Street Name <br />City <br />CONSUMERCLEANUP <br />SITE (LOP) <br />{ETHER CLEANUP SITE (NON -LOP) <br />IT111 <br />rpm rte(\'� <br />{(,� <br />1,1 <br />►AV,�{�^�{i <br />2 <br />((r] O <br />n , <br />M1 iS.! <br />muck l � ' <br />Draav <br />I <br />AZARDOUS WASTE <br />�IERED PERMITTED FACILITY <br />ABOVEGROUND TANK <br />VI (MONITORING / REMOVAL) <br />IIIIIIJJJJJJ <br />"/� <br />3 <br />t I � <br />I <br />sE �' <br />l ❑PWS <br />HAZARDOUS MATERIALS <br />ILURELEASE RESPONSE <br />i' <br />i <br />`Oi <br />Q WATER QUALITY <br />lS <br />$OLID WASTE FACILITY / VEHIOLE <br />q <br />L7 <br />- <br />�J <br />FOOD FACILITY <br />` <br />SITE MITIGATION <br />POOL/ SPA <br />DAIRY <br />LAND USE APPLICATION SITES <br />5"SEPTIC TRUCK/ <br />J <br />n <br />HGuau:G <br />PUMPER <br />TOILETS <br />YARD / CHEMICAL <br />.dWASTEWATER TREATMENT PLANT <br />7 <br />/� /� <br />V11V' <br />..�• <br />y� ff G <br />t� I.•tt� <br />u��� <br />CUPA <br />HOUSING ABATEMENT <br />' , 1 <br />MOTEL/HOTEL <br />CHICKEN RANCH /DOG KEIJNEL <br />MEDICAL WASTE FACILITY <br />ZA <br />Y � J <br />OCUPA-HAZ-MAT <br />1\ q • � ^ ,_ ^ / � �� / <br />TATTOO/BODY PIERCINGr <br />n WASTE TIRE <br />`QOMPLAINT <br />9 <br />/�� _ p <br />�{ �Q, b� <br />�// j[y�SOLID WASTE <br />4 <br />THER(PL� E SPECIFY): � � <br />VuC. V <br />ACCOUNTING <br />•"'BOXED AREA - EHD USE ONLY"' <br />