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DALEqLY, EHD LOG NUMBER <br /> 1� �) SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> DEC WS Telephone: <br /> East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sigov.org/ehd <br /> EIkJtROS1tiP�EivTAL14EALTII PUBLIC RECORDS RELEASE APPLICATION <br /> .nr_c <br /> APPLICANT: SO!J 6 AA11,5 Le BUSINESS/AGENCY: <br /> ��£/JS'7-`t' ;cF (;-fiC,,{; ,lfrrC• <br /> ADDRESS: CITY/STATE/ZIP: <br /> �} Ct 12 <br /> PHONE (1): (. ��. (F}a PHONE(2): TiStr y �: 6y j FAX ORE-MAIL: oC E� 'CGre- <br /> Please allow 10 business days from date of application submittal for the records to bt4vailabld. <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑CHECK BOX TO EXPEDITE REQUE $13 (C'ASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT r ��, DATE (n�(U//.— <br /> Electronic Information: [jX-i-st❑ Map-Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street# Street Name City <br /> 1. 1?,'�,5 A CM' II:P WAV v LAI S-t "�f Q9P,,p y 1 -Cro ❑Unit 1 <br /> 2. [ A-CD - <br /> 3. V� �- kv-C_�J (A UT-it <br /> — 144. .�j�7 ❑Unit 2H <br /> s. jc� 11V-cD k5-r-cD t 3 �l3 <br /> ni <br /> r" f ( [ _ <br /> 6. Ww: �� /'llt(,+l+H CJf /4 11 �'' Unit 3HM <br /> 7. 0.4 rf ftJ�A`It 4k ca nit 4 <br /> B' oiY/11 EKSITE MITIGATION <br /> 1 D. mt s <br /> Specific Date Range of Information Requested: From to i <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILESDU <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MOTELIHOTEL SOLID WASTE FACIUTYIVEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT FOOD FACILITY <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑WASTE TIRE ❑DAIRY,POOL/SPA <br /> ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTE ❑MEDICAL WASTE FACILITY PUMPER TRUCK[YARDICHEMICAL TOILETS <br /> HAZARDOUS MATERIALS ElTATTOO/BODY PIERCING E]LAND USE APPLICATION SITES/ <br /> TIERED PERMITTED FACILITY ❑COMPLAINT/RESPONSE RECORDS [7g'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 notbe 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$130 deposit prior to review. <br /> i ***BOXED AREA-EHD USE ONLY*** <br /> PWu ISA L 5 l N05 s.. 1%1 L 0 k,% tA, ela'141 1-(V 4465 4,7f I30r, ftAl 18)- <br /> 1 A CQ r7,tg71-5 t t V J Lr I f&,75 <br /> CoZ ,4 :j 1' t,. Ve 1f� I (&,w " 1 r LOw I� <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: 9ty'7 t9f 8011 r V,h CO- <br /> n�d.�. <br />