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RERE UVED • • EHD LOG NUMBER <br /> ,4E JOAQUIN COUNTY <br /> DEC 12 2D14 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> F—WIRONMENTiM- Ng"ffe: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: '�311.\)v\, V\� e, 4 BUSINESS/AGENCY: fz / lE <br /> ADDRESS: L {�—D \,Q Qy.� CITYISTATE/ZIP: �nz' <br /> PHONE (1):Gt, (6 (9 0,9 S '77hPHONE(2): FACSIMILE:CVC, <br /> Lnr�H�� <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 /> El CHECK BOX TO EXPEDITE REQUEST-$135/_55'�EE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY t l <br /> Street# Street Name city Unit1 <br /> 2; "'e---NUnIt20 11 <br /> 4• <br /> S. <br /> 6. <br /> El Unit <br /> 7. <br /> 8. <br /> ❑ Unit 5 <br /> 9. <br /> 10. ❑ UnIt 6 <br /> Specific Date Range of Information Requested: From to I i <br /> ENVIRONMENTAL HEALTH DEPA T ENT FILES <br /> IylNnFera"91-I+un-ZauK-(LST}G.L-EANURS4T 1 OP)_ ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILOY1VEHICLE <br /> L7crintrc�[EANfIPS (NONaI-®R)— ❑HOUSING ABATEMENT ❑WASTETIRE i0 <br /> [-tTDERGROUND TANK(MONITORING/REMOVAL) ❑FOOD FACILITY ❑DAIRY3- <br /> �K ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> �AZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICALTOILETS <br /> �iER ILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ^`iOjR1LLD^"^- ❑COMPLAINT/RESPONSE RECORDS <br /> ❑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 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$125 deposit prior to review. ***BOXED AREA-EHD USE ONLY*** <br /> I- 5 r r U.` <br /> 7'I A'0 of ti / <br /> *I 633© <br /> Q A4 62 IP f-&IAIO C4 t,M 8reero <br /> EHD 48-06 4128114 <br />