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EHD LOG NUMBER <br /> DATE RE EIVED SAN JOAQUIN COUNTY <br /> WED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> DEC 2 3,2015z 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: wwvv.sjgov.org/ehd <br /> EfSti�ticE F't" S"r:` L! d;L(iG <br /> =r=�4, PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: Avnj BUSINESS/AGENCY: t"�Y <br /> ADDRESS: CITY/STATE/ZIP:I:GSC.+�'1�✓t�j (L— ' (CX .E <br /> PHONE (f):�7?3� ��✓— � �4% PHONE (2): FAX OR E41AIL: <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-$130 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT li f^ FCrc i �:�. DATE <br /> Electronic information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City <br /> Fa PV641c4') C", 04W <br /> [I Unit 1 <br /> 2. <br /> 3. GDF.SZ d�3 [� �ew 1z�zo/5�, 0000`�7/`l�tw lllZO1S� <br /> W6nit 2 <br /> ���3a3 �ew �f/�o15.� <br /> 4. (C�(L G�'Gnit 2H <br /> 00003 10 pe+ylob' +00�3�577 E �� Co 00,> 7� Pi� <br /> 5. y7 )J LOCO 45 7CXoLOI��' �Z r ✓10(0 ©Golf 3 <br /> 6. �(c�o,P�M3(70 Z <br /> (,D�eo�NICO b f � (A��� 7 5106 I (.(r)Wr77 �nit3HM I <br /> 7. wt �Y2� rvjtilo(v� W002 �P+y(0(-" tppouf5yq? ���, <br /> �IaO , nit 4 <br /> 8. ( Q0Z I b tI r S I(X� �� 13 Sl�,� / S�p�� Qk6lTE MITIGATION <br /> 9. 60001,56 r(' r"& v(pl6Nzq r 45toQ wool$_3bz�ipt�. <br /> c80D1 ga3(o r�151E� 00 l F1�1 Z rPt 510 � jy1 X514 C�r � <br /> 10. 001 gQZ, Ptyl�� cp�l�(d rpf r71d0 Gt7G�/'73�b�t P151 nit s <br /> Specific 5106��� 1�� �� � t�14°l$S� SiG�)� to <br /> Ls <br /> and W � +n�l I1-WF��e• I[2 UMC 40 <br /> L]SOLID WASTE FAC WTYNEHICLE / <br /> Q OTHER CLEANUP SITE(NON-LOP) �IoUSING ABATEMENT [:]FOOD FACILITY x-- ` !� /til 1 <br /> ❑''UNDERGROUND TANK(MONITORING/REMOVAL)v� &J*ASTE TIRE ❑DAIRY,POOL/SP � 2 <br /> ^,^,,A�BOVEGROUND TANK — ❑CHICKEN RANCH/DOG KENNEL RWASTEWATER TREATMENT PLANT <br /> a0AZARDOUS WASTE C"( ❑MEDICAL WASTE FACILITY ❑PUMPER TRUCK/YARD/CHEMICAL TOILETS <br /> AZARDOUS MATERIALS ❑TATTOO/BODY PIERCING ❑LAND USE APPLICATION SITES 'A � � <br /> ❑TIERED PERMITTED FACILITY ElCOMPLAINTIRESPONSE RECORDS �OTHER(PLEASE SPECIFY) -`i'I4�"�l l <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(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 /> 11y-15 <br /> 0 Records provided by Staff-PPR Complete. Staff Name: <br />