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DATE RECEIVED <br />RECEIVED <br />lephone <br />OC 1�1 T ZR <br />S. <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main St. Stockton, CA 95202-3029 <br />(209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />ENVIRONMENTALLTH <br />PFRiUn"/SFRVIrFRRVif:FR PUBLIC RECORDS RELEASE APPLICATION <br />, <br />c,r ila P4l P j i T (►4 r k i. i � %l <br />APPLICANT: GJ1/}rl�i s`BUSINESSIAGENCY: <br />EHD LOG NUMBER <br />ADDRESS: 0/ �k T7—(ju,-i � T CITY/STATE/ZIP: %U f� <br />PHONE (1): �°Gf ' Y d S r X413 PHONE (2): 2- 0-1 r 6 4 - /i r FACSIMILE: <br />TENTAT/VE*APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application submittal -'Tentative only - must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST 125 FEE (CAS OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANTDATE <br />Electronic Information: ❑ List ❑ Map — Description: <br />Date Range of Information Requested: From <br />FILE ADDRESS <br />EHD USE ONLY <br />❑Unit 1 <br />[qV6NbERGROUND TANK (UST) CLEANUP SITE (LOP) <br />Street # <br />Street Name <br />City <br />1 • <br />❑ DOG KENNEL <br />ARDOUS WASTE GENERATOR/- <br />Bt2SED <br />❑CHICKEN RANCH <br />5 . ❑ Unit 2 <br />nit 3 <br />2. <br />3. <br />l <br />y(= 1( A)Q f b• , I.v <br />"-a C o <br />4• <br />5. <br />Unit 4 <br />6. <br />- <br />7. <br />❑Unit 5 <br />8. <br />9. <br />_ <br />❑ Unit 6 <br />10. <br />Specific <br />Date Range of Information Requested: From <br />I ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />[qV6NbERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />❑'C!T,HER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />❑; NDERGROUND TANK (MONITORINGIREMOVAL)V <br />❑ DOG KENNEL <br />ARDOUS WASTE GENERATOR/- <br />Bt2SED <br />❑CHICKEN RANCH <br />PERMITTED FACILITY`x- <br />❑ MOTEL/HOTEL <br />❑ TATTOO/BODY PIERCING <br />❑ POOLISPA <br />❑ MEDICAL WASTE FACILITY <br />❑ COMPLAINT RECORDS <br />_ to eC) <br />i <br />❑ SOLID WASTE FACILITY/VEHICLE `�\ �� // , <br />� 'J <br />❑ WASTE TIRE 1 ' ^ <br />❑ DAIRY 1 A\ <br />❑ WASTEWATER TREATMENT PLANT <br />❑ PUMPER TRUCKIYARD/CHEMICAL TOILETS <br />❑ LAND USE APPLICATION SITES <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 - for additional assistance with file addresses, contact the EHD. Applications received after <br />3:00 pm will be processed the next business day. <br />2. 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 />3. A file that is actively being worked on by EHD staff may not be immgd)'ately av ' able for rev'p. . A new applic t'o ma <br />submitted when the file is available.l^"/�1�I-r�i�-t Z-)� �r�%lt L� <br />4. Any file not returned in the same condition as releasA Vn be"r orgYd1fe�l`K staf �tp�F�S'� bT �I 6 �plic nt.k6 <br />Future file reviews by the same applicant may require a $125 deposit prior to review. 10,. Z0� I a agpiGUrt #-�3422�] <br />r <br />I I iii - I -7-A1 t 1A) -r (/1 IA" k\.. 7 +h fti-b , 164-1> EHD USE ONLY %9;W, `314 _7;�I Q/Y`P i A (ami T (-71/- ter Ith litA )za. V <br />- Il I I t -I 5 U-9 rpt <br />EHD 48.06 5Id Fyy Elld;`�i4vj5�#Si/l U5eby M._ a 111 <br />