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e! 01/01/2010 00: 19 2093398 MIDCAL INDUSTRIJ6 PAGE 01/01 <br /> e <br /> ® ® o 21V ) SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> ®� ENVIRONMENTAL HEALTH DEPARTMENT <br /> SEP 10 2015 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgpv.org/ehd <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> J / � �� / �APPLICANT: M` - AQ1;9 <br /> ADDRESS: leq#J �//YI7y fiOOV C7CITY/STATE/ZIP: 5-7d-61--W- u <br /> PHONE (1): PHONE (2):26,33FACSIMILE: r—FC— <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 appoin t date and time to review the requested records, <br /> ❑ CHECK BOXTO EXPEDITE REQUEST- E ASH CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT /lire DATE 9 — '9 <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS <br /> Street# Street Name City EHD USE ONLY <br /> 2• �/3 -7 3_ S-leek .5r ocXram 5 Y <br /> reW' <br /> 3, <br /> El Unit 2 <br /> 4. J,`i�e GFlle. 0 UnA2H <br /> 5. ( �r� q/ <br /> 6. <br /> 7. Ld'"Llnit a <br /> 8. Ly'SITE MITIGATION <br /> 10. <br /> ❑Unit 5 <br /> Specific Date Range of Information Requested From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> DERGROUNDTANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ElSOLID WASTE FACILRYNEHIC LE <br /> OOTHERCLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> MgNDERGROUND TANK(MONITORING/REMOVAL) F]FOOD FACILITY El DAIRY <br /> gOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER 7RUCKIYARDICHEMICALTOILETS <br /> ❑TIERED PERMITTED FACILITY. ❑POOL/SPA ❑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-S: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 pnt 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 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,rnequire a$130 deposit prior to review. *"BOXED AREA.EHD USE ONLY"' <br /> uJA CJACvn a� k4 9, a1 ), t J Le #z+4rN - j ell 4v-qvlr <br /> A/0. / 11 ofk —Coe t r, O 6+0 e91-75 i ✓1 1 II r I <br /> d!C C Iw`r-k CO c� I-lo`3'821 s1�-0-e l-ll.l ♦'ile. �r 0Z5 N Or, <br /> ❑ Records provided by Staff-PPR Complete. staff Neme: <br /> Received Time Sep, 10, 2015 9: 13AM No. 9539 711115 <br />