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lill_IL-10-c01� 13:10 FRri,1:TC1HN & CC 'F'''r T 15401-3 P.1/1 <br />I� <br />I! <br />qECEiVED <br />EHD LOG NUMBER <br />! , ENVIRONMENTAL HEALTH DEPARTMENT q <br />` a 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />elephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />_NMRONMENTAL HEALTH <br />PERMITfSERVICES PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: - C [ �l C�-t�<�2S BUSINESSIAGENCY: <br />ADDRESS: _ 4/ lvv6?, CITY/STATE/ZIP: <br />PHONE (9),-& trelk 622? PHONE (2)aO FACSIMILi ;.�tJ� <br />771 <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 appointmZdatnd time toreview the requested records° <br />CHECK BOX TO EXPEDITE REQUEST - $130 E ( SH ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE <br />Electronic Information: ❑ Li ap– Des cr on: <br />LE ADDRESS <br />EHD USE ONLY <br />[J Unit 1 <br />(] Unit 2 <br />straot # <br />Stroot Name <br />city <br />L <br />4-4 <br />-- <br />2. <br />-� ` (' <br />:� i < j c% �1 _ % �? / l '> <br />' ✓_ 7 <br />3. <br />J <br />��(e� - <br />❑ Unit 3 <br />4.`Jl�vitrl <br />5. <br />Qt2i"n <br />�'l�")� El-'Unit4 <br />6. <br />7. <br />S. <br />❑ Uflft� <br />9.. <br />Unit <br />��ERG� <br />ate Rango of Information Roquestad: From �— 1*� /� to 7—Z -2—a— <br />'0 <br />" Z2 — S <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />OUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILrrY SOLID WASTE FACT! (T(IVEHICLE <br />T EANUP SITE (NON LOP) ❑HOUSING ABATEMENT ❑ WASTE TIRE <br />RGI3OUND TANK (MONITORING/REMOVAL) ❑ FOOD FACILITY ❑ DAIRY <br />B GROUND TANK ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER TREATMENT PLANT <br />DOUS WASTEiHAZARDOUS MATERIALS ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARD/CHEmicAL TOILETS <br />TIERED PERMITTED FACILITY ❑ POOLISPA ❑LAND USE APPLICATION SITES <br />❑ TATTOO/BODY PIERCING ❑ COMPLAINT(RESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <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 Flies 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 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. Thu 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 $130 deposit prior to review. " BOXED AREA - EHD USE ONLY— <br />ct'n� W ocIti7-5'd '' -646 <br />-Records provided by Staff -PPR Complete. staff tdamo: <br />__�HD0-06 - --- --- — — — --------06101114 <br />Received Time Jul. 10. 201 1:17PM No,9120 <br />Ar <br />