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DAnSeP, 22. 2015 2; 13PMNo. 1911 ETP. 4 <br /> • SAN a�OAQUIN COUNTY • G NUMBER <br /> C*`3 V ENVIRONMENTAL HEALTH DEPARTMENT <br /> OCT 14 2015 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> . Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> ENVIRONMENTALHEAL►HPUBLIC RECORDS RELEASE APPLICATION <br /> _n—rtae�rin_rM1ICF,% nn � <br /> APPLICANT.,_ M C�r(1n CC BUSINESS/AGENCY: O� COl cnt), pujo(,l_ wba__ <br /> ADDRESS: (81c) -e. atvn Nt CITY/STATE/ZIP: Mem Cq <br /> PHONE(t): PHONE(2): FACSIMILE: 6,' � L4LQ— z-qqGj <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- 130 F E(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT �( y - DATE 9 14-f,- <br /> Electronic Information: ❑ List Map—Description: <br /> FILE ADDRESS <br /> '-streat Name City EHD USE ONLY <br /> 1 (P S W In/GLINt p( I J� SID� Y1 W F1 P-�D <br /> 2. <br /> L�Unit 1 <br /> 3. <br /> ®,Unit 2 <br /> 4, �� <br /> 5. MUnIt2H <br /> s. l <br /> It 3 <br /> 7. ,_,,� <br /> L�d'Onit4 <br /> 6. <br /> 0 SITE MITIGATION <br /> 9. <br /> 1Q. f <br /> SpaclHo Date Range of Information Requested: From - to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> O-UNDERGROUND TANK(UST)CLEANUP SITE(LOP) MEDICAL WASTE FACILITY SOLID WASTE FACILITY/VEHICLE <br /> ®OTHER CLEANUP SITE(NON-LOP) ®HOUSING ABATEMENT WASTE TIRE <br /> '0UNDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ,@ DAIRY <br /> t�ABOVEGROUND TANK -®.'CHICKEN RANCH/DOG KENNEL WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTE/HAZARDOUS MATERIALS <br /> ❑MOTELJHOTEL .PUMPER TRUCK/YARD/CHEMICAL TOILETS <br /> .� <br /> TIERED PERMITTED FACILITY POOLISPA <br /> ❑TATTOO/BODY PIERCING COMPLAINT/RESPONSE RECORDS LAND USE APPLICATION )TES <br /> _ ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REviEW: MONDAY-FRIDAY B:DO 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(2D9)464-0136 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 schadulod accordingly. <br /> 4. Anyfile 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 /> n o.......d.. ..rr...:.4..-� y�. ca.Tfe nnn n0�_�_�_ Staff Name: <br /> Received Time=Sep. 22. _2015= 2: 09PM�No. 9621 <br /> EHD 4808 <br /> 7/1H5 <br />