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DATE RECEIVED EHD LOG NUMBER <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENTV, <br />. <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />elephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: t1 ��c't [_CV /Nr <br />�. BUSINESS/AGENCY: �-•'L`�- �' �t `�--�i� <br />ADDRESS:33� �. `f d ja�� CITYISTATE/ZIP: 0:4 12. CCC �fL.t? <br />PHONE (1): 2�i�`s`� -�l7 PHONE (2):"ZO 9 4%_t S31 Z- FACSIMILE: <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 - $13 EE (CASH OR CHECK ONLY) -REQUEST PROCESSED IN 3 BU ILS <br />AYS <br />SIGNATURE OF APPLICANT �"`=� DATE `3 It <br />Electronic Information: ❑ List ❑ Map — Description: <br />114's ('V 6" 4,\ -e (00OU067 a -,a <br />FILE ADDRESS <br />EHD USE ONLY <br />k/'F(- El Unit 1 <br />lAW( anL•"ti A CIO. <br />Street # <br />Street Name d <br />city <br />❑ Records provided by Staff -PPR Complete. Staff Name: <br />2. <br />.`i�i <br />t`+ • "c�"��tp+ rid r <br />P`,v --� <br />3. <br />Z-5 (1 S1 <br />S • t'^��.�(� <br />i <br />A,,\ '+.ii <br />��U�ejLt,55 it2 <br />4. <br />5.(�q2. <br />2-5 <br />% <br />3lrf5so c rr <br />nn <br />V1 �T ❑ Unit 2H <br />-2�-� <br />CLeThit 3 <br />(6 <br />c 2 <br />7.�(��Jd <br />g�j <br />!�/.��� <br />1/JC��'Ga <br />nit4 <br />8 <br />2 `L l) <br />R �� <br />l oc s P -d <br />C��-c <br />�,�11 V. �"b�C�C.() �Qlnit 5 I <br />9. <br />2 i V <br />,,� <br />f~� ft -46 < <br />-- <br />/Lo <br />10. <br />I f(! 62 <br />tj L-2L�C,--k r I <br />f��-icy ;r) <br />Specific Date Range of Information Requested: From 15 CD to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />NDERGROUND TANK (UST) CLEANUP SITE (LOP) [IMEDICAL WASTE FACILITY E]SOLID WASTE FACILITYIVEHICLE <br />[ABOVEGROUND <br />THER CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT ❑ WASTE TIRE <br />NDERGROUND TANK (MONI TORINGIREMOVAL) ❑ FOOD FACILITY ❑ DAIRY <br />TANK ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER TREATMENT PLANT <br />AZARDOUS WASTEMAZARDOUS MATERIALS ❑ MOTEL/HOTEL ❑ PUMPER TRUCKIYARD/CHEMICAL TOILETS <br />❑ TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br />❑ TATTOOIBODY PIERCING / COMPLAINTIRESPONSE RECORDS OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:OOPM (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. 'BOXED AREA- EHD USE ONLY` <br />5-106 Ire(/ C 9 r- Cow..ar (Ova <br />114's ('V 6" 4,\ -e (00OU067 a -,a <br />C O 17 e '.n {krt 1 V k <br />(i r 0-470 Lye -IV- 96 -)"'ACA KM le OL L LUV-* R,1 <br />lAW( anL•"ti A CIO. <br />A,4(jej tA S (1662- R 00 - PAJ1vUAOcWl <br />Ct I Z 47r') <br />I{ <br />❑ Records provided by Staff -PPR Complete. Staff Name: <br />EHD AR -0r, <br />711/15 <br />kAl <br />