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�n,p+ EHO L13U NUMUtK <br /> fIffQ �D SANJOAQUINCOMVON ( ( �lOb 'S 'dos awll paniaaaa <br /> EN IRONMENTAL HEALTH DEPARIMENT <br /> SEP 5 2013 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> EN MENTAL <br /> PERMITISERVICHESLTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT:Ax4,re,w f1� LIaCe BUSINESSIAGENCY: AFT La1.5a)+aa +S <br /> ADDRESS: CITYISTATEIZIP:V,1+ za{-(ire eV,&,,q597 <br /> PHONE(1): �gtS�-]NF^ KOt90 PHONE(2): FACSIMILE: <br /> TENTATIVE'APPOINTMENT DATE. Time: <br /> (Please allow 10 business days from date of application submittal-"Tentative only-must he confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT, E-lyze DATE 9 S 7-013 <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street if Street Name City 171uniti <br /> ems. + usr v H <br /> p 07 O.yAe ST T _ 'y <br /> t 2. Bao ry. 5fi T c srj Unit <br /> S-" I <br /> 4. _ ,EfU.it 3 <br /> r77. <br /> ElUnit 5 <br /> 10. E]Unit 6 <br /> Specific Data Range of Information Requested: From to <br /> �/ ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> E UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYNEHIC } <br /> ❑�,,JJppTHER CLEANUP SITE(NON•LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> Ly NDERGROUND TANK(MONITORINGIREMOVAL)� ❑FOOD FACILITY ❑DAIRY (C( ( 3 <br /> L.y.,[��pOVEGROUND TANKS ❑CHICKEN RANCHI DOG KENNEL ❑WASTEWATER TREATMENT NT <br /> LyHAZARD0U5 WASTEIHAZARDOUS MATERWLS�� ❑MOTEUHOTEL ❑PUMPERTRUCKIYARDICHEMICALTOILETS <br /> ❑TIERED PERMITTED FACILITYOOLISPA [ILAND USE APPLICATION SITES <br /> ❑TATTOO113ODY PIERCING - WOMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> 1. List up to ten addresses In the space above. Selectthe type(s)of flies from the list above by checking the appropriate <br /> 1 ox(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 Immediately available for review. A new application may be <br /> submitted when the file is available. <br /> 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the ex ense of the ap licant. <br /> Future file reviews by the same applicant may require a$125 deposit prior to review. <br /> f Croft 1 �f <br /> ._.. .. J <br /> _..rt. #5 : I�Iq d- . W. O _1 • ' 5146) a Q i/1 �. tW h� r ela z� <br /> EHD 4B-05 ,{,r,,'�d/1 ^,�� '� <br /> Z0/T0 39t?F / S1Nvi-inS1,100 I3d 6GO99PL976 OT:TT ETOZ/90/60 .�, <br />