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DATE6EGfIVED, 2dj6 SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> E�ylLc�[,�,;y; fisTfAt-F�-� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 9g�,c,4T _C/ICES Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: �VFc torvr' BUSINESS/AGENCY: b"Ie/yy. <br /> ADDRESS: L?R21 %ej4L, E', S CITYISTATEIZIP:-Se�/erk/a 9R11R <br /> PHONE(1): Z0/i_AfA_ 1533 PHONE(2): FAX ORE-MAIL: <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-$139 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE rnsn �ii. <br /> 1. List up to ten addresses in the space below. Select the type(s)of files from the list below by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to1209)464.0138 or mall 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 It 0) <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$139 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> Electronic Information: [List❑ Map—Description: <br /> Specific Date Range of Information Requested: From W_41es to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES EHD USE ONLY <br /> GKNDEROROUND TANK(UST) Street# Street Name City <br /> CLEANUP SITE(LOP) / 1A�n �CwsVNFP LV <br /> HER CLEANUP SITE(NON-LOP) /f Cil I� ; 6D ,O IA �I�t <br /> U dKGMOUS WASTE vJa.JV •✓1 v 7�'' <br /> []OMR <br /> ❑TIERED PERMITTED FACILITY3 <br /> @�<_EGROUND TAHx <br /> Q.eST (MONITORING I REMOVAL) O PVys <br /> �(ARDOUS MATERIALS 3 <br /> pIIRFLEASE RESPONSE <br /> ' ❑SOUR WASTE FpGIL1TY/VEHK:LE + <br /> WATER QUALITY <br /> ❑FOOD FACILITY <br /> (� ❑POOL/SPA SNE MRIGArpH <br /> ❑DAIRYe ' (,,,tttl <br /> 5 ❑"NO USE APPLICATION SRES Vl{�,r <br /> ❑SEPTIC PUMPER TRICK I ❑HOUMA4 <br /> YARD I CHEMICAL TOILETS E <br /> " ❑WASTE♦VATER TREATMENT PLANT <br /> ❑HOUSING ABATEMENT T CUPA <br /> ❑MOTEUHOTEL <br /> ❑CHICKEN RANCH I OCG KENNEL CUPA-UST <br /> ❑MEDICAL WASTE FACILITY S <br /> F-1 TATTOCIEGOY PIERCING <br /> F)GMI ❑WASTE TIRE ❑AVN WASTE <br /> 9 <br /> j ❑COMPLAINT <br /> M ❑OTHER(PLEASE SPECIFY): <br /> A.UNH ,Na <br /> 1D <br /> E "'BO%ED AREA-EHD USE ONLY"• <br /> t . <br /> f, <br /> t O Records provided by Staff-PPR Complete. staff Name: <br /> F� EHD 4845 <br /> 1 <br />