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DATE MA05SAN JOAQUIN COUI4TY _ <br /> - -RONMENTAL HEALTH DEPARTMENT (��-��f <br /> E?IVII OMMENTAL HEAL 186t�'"st Hazelton Avenue, Stockton, CA 95205 6232`'oL <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:wvvw.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> EUSIh ESS1ACsENCY: Mccl � ;3 � � <br /> .,PLICANT: G!c t' ' T CITYISTATEr IP: t -to �g i4 <br /> ADDRESS: FAX OR E-MAIL.: <br /> PHO14E(1): �Mo—(;1iC�� PHONE(2): <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff vwlill contact you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$130 FEE { QATE r-),97 C)_5 I(- <br /> CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINES DAYS <br /> SIGNATURE OF APPLICANT <br /> 1. List up to ten addresses in the space below. Select the type(s) of files from the list below by checking the appropriate <br /> box(es). At least one file type MUST be selected. Far,to 209 464-0138 ar 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 cond'tion as released will be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviewsby the same applicant may require a$130 deposit prior to review. <br /> WELL AND SEPTIC PERIJIT RECORDS ARE AVAILABLE FOR REVIEkht: [MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List ❑ Map—Description,: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL � � xo5 �r C,WT � �� <br /> HEALTH DEPARTMENT FILE ADDRESS EHD USE � LY �y �J <br /> FILES <br /> Q UNDERGROUND TANK(UST) Street Street Name City <br /> ,,CCC,,LEANUP SITE(LOP) J��j r A lv i!1 f� ❑LDtJSUMER <br /> '0THER CLEANUP SITE(NON-LOP) ' (�'-t"`1 ��IVd bl fM `- , (� <br /> IHAZARDOUS WASTC S � DAIRY <br /> TIERED PERMITTED FACILITY Z n Iy�R� rA r -70 <br /> dABOVEGROUND TANKS( th <br /> LIST (A 1 ;D A I i I ,�/�/�Cyf��//] PWS <br /> HAZARDOUS MATERIALS <br /> 21SPILURELEASE RESPONSE - - <br /> VJATER CaUALITY <br /> F5IAO <br /> OLID WASTE FACEUTY I VEHICL 4 �` ✓n <br /> F1FOOD FACILITY `( - ft (�f <br /> ' <br /> POOL/SPA SFE MITIGATION <br /> ❑ ✓ J�5 <br /> ❑DAIRY I !�i t(JU �`V � • J A)9[/-b) IVO 61'915-10 <br /> 5-10 <br /> ❑LAND USE APPLICATION SITES I C I Imo/ l HOW"tNG <br /> ❑SEPTIC PUMPERTRUCKI NO [:] <br /> I <br /> YARD I CHEMICAL TOILETS <br /> 67" S` v n <br /> &WASTEWATER TREA7MENT &) <br /> PLANT A , � �CUPA <br /> F-1HOUSINGABATEMENT 7 1 t�� I ���������� r`A' ��- (J P�nf� <br /> F-1 MOTEL/HOT-EL <br /> 4l L V u <br /> ❑CHICKEN RANCH I DOG KENNEL ,a.V❑ ( (�,., UPA-HAZ-MAT MEDICAL WASTE FACILITY 1 <br /> 111 1 ♦ • <br /> ❑TATTOCIBODY PIERCING <br /> SOLI°WASTE <br /> FWASTE TIT g `� 1 1• Why <br /> f <br /> COMPLAINT y�(nljl (l-hC/JAl�t+l[ <br /> Q QTHER(PLEASE SPECIFY): ACCOUNTING <br /> lull f S r '° '1 �", [o �� , <br /> -*BOXED AREA-END USE ONLY"' <br /> '1 LVAq �v,r 4r, C-a-'o <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 48.05 <br />