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ELM <br />■ Ling Cao Fax: (6161 346-7788 To: 2094640138@rcfax.can Fax: (209) 464-0138 Page 1 of 1 06/0112017 10:48 ANI <br />� � IV SAN JOAQUIN COUNTY EHD LOG NUMBER <br />■ ENVIRONMENTAL HEALTH DEPARTMENT g4 116 ■� JUN 0 1 2011 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />�1tVIRQPINIITAL t M7H <br />PEW rWZEM— C t :" PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: AmadaLagunas BUSINESS/AGENCY: Fulcrum Environmental <br />ADDRESS: 517 South Ivy Avenue CITY/STATE/ZIP: Monrovia, CA 91016 <br />PHONE (1): 626-228-7361 PHONE (2): FACSIMILE: 800-385-7126 <br />ama a renviro.com <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 appoi tment date and time to review the requested records. <br />7_1CHECK BOX TO EXPEDITE REQUEST- 8 30 FEE (C H OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS/G) <br />SIGNATURE OF APPLICANT DATE 6-1-17 / l <br />Electronic Information: ❑ List ❑ Map -Description: hazardous releases/materials: UST/AST; septic systems <br />FILE ADDRESS <br />EHD USE ONLY `b1'(� 6MStiC <br />1.1 <br />Street # <br />1190 <br />Street Name City <br />East Locke Road Lockeford <br />2. <br />3. <br />vJrck2/ <br />L <br />SITE MITIGATION <br />4. <br />5. <br />6. <br />❑ <br />7. <br />LV'A-Hh <br />_(7 <br />8. <br />9. <br />I (-WA - (A -T <br />M/ <br />10. <br />1 <br />Specific Date Range of Information Requested: From all \lo all <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY M SOLID WASTE FACIUTYNEHICLE <br />®OTHERCLEANUP SITE(NON•LOP) ® HOUSING ABATEMENT ®WASTE TIRE <br />® UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ FOOD FACILITY ❑ DAIRY <br />® ABOVEGROUND TANK ❑ CHICKEN RANCHI DOG KENNEL ® WASTEWATER TREATMENT PLANT <br />[HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL❑r�r1 PUMPER TRUCKIYARDICHEMICAL TOILETS <br />M TIERED PERMITTED FACILITY [:]POOLISPA L'J LAND USE APPLICATION SITES <br />❑ TATTOOIBODY PIERCING [XCOMPLAINTIRESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:OOAM-5:OOPM (EXCLUDING HOLIDAYS) <br />1. List up to ten addresses In the space above. Select the type(s) of flies from the list above by checking the appropriate <br />box(es). At least one file type MUST be selected. Fax to (209) 464-0136 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 flies exist. An appointment for review will be confirmed approximately ten (10) <br />days after receipt of application. The flies 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 $125 deposit prior to review. ***BOXED AREA -EHD USE ONLY*** <br />Z-1'1-1-G_11P1 nn. rll6rt-lEi AL -IL „I -k 41.1 11&] ,.A, -ll VA f I-.. G(a. i L,n6. <br />Staff Name: <br />eceived Time Jun. 1, 2017 10:44AM No. 1618 <br />