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08/10/2014 14:47 FAX 2 <br />DATE RECEIVED x;97 <br />�n a i-4v <br />SAN JOAQUIN COUNTY � a <br />.dENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 Rol <br />AUG t OT&Qhone: (209) 468-3420 Fax: (209) 464-0138 Web: www,sjgov.org/ehd <br />RECORDS RELEASE APPLICATION <br />APPLICA�T: A Po L 1-40 BUSINESS/AGENCY: c' sta I-{- <br />ADDRESS: A~%ock 15�00 CITY/STATE/ZIP: (e.,-�- CeD f �' <br />PHONE (1): J,� o- 3-1,,34-5 PHONE (2): —)a Q 14-o FACSIMI : <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 data and time to review the requested records. li' <br />CHECK BOX TO EXPEDITER EST - $125 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />2 �l2� <br />SIGNATURE OF APPLICANT ¢ DATE <br />Electronic Information: ❑ List ❑ Map — Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />� El Unit 1 <br />Street # <br />street Name <br />city <br />1 Q <br />M. <br />I \ . H W til 1 � <br />rv1on <br />MP j 7� n1 C C4l�P <br />Iim. - '� s— 4 M M � Unit 2 <br />��o►+�..� <br />x <br />A Unit 3 <br />t4- <br />i5. <br />_ - CJOt4 <br />UJ I '- <br />. Li r}J • '� y _3V <br />� .?.:�5 � <br />7. <br />❑ Unit 5 <br />9. <br />Unit 6 <br />10. <br />Specific Date Range of Information Requested: From a OD roo to '^r <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES��� <br />'UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILrrY ❑ SOLID WASTE FACIUTYIVEHICLE <br />[?'6'THER CLEANUP SITE (NON -LOP) ❑ HOUSIND ABATEMENT ❑ WASTE TIRE <br />E"ONDERGROUND TANK (MONITORINGIREMOVAL) ❑ FOOD FACILITY ❑ DAIRY V' A <br />g -ABOVEGROUND TANK ❑ CHICKEN RANCHI DOG KENNEL ❑ WASTEWATER TREATMENT PLANT � <br />Q'AAZARDOUS WASTE/HAZARDOUS MATERIALS ❑ MOTEUHOTEL ❑ PUMPER TRUCKMARDICHEMICAL TOILETS l 1' <br />❑ TIERED PERMITTED FACILITY ❑ POOL/SPA ❑ LAND USE APPLICATION SITES <br />❑ TATTOOIBODY 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 />I. List up to ton addresses- In the space above. Select the type(s) of filen from the [list above by chocking the appropriate <br />box(es). At least one file type MUST be selected. Fax to (2091464-0138 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 bucinoss 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 exlat. An appointment for review will be eonflrmed 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 />GA- a $ �` <br />S Serra &c3 Se `tel <br />❑ Records provided by Staff -PPR Complete. Staff Name: <br />EHD 48-06 4r28114 <br />Received Time Aug. 20. 2014 1:51PM No, 6874 <br />