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05/23/2017 11:37 9166486688 ADR PAGE 01/01 <br /> • D��E7VL-IV9 EHD LOG NUMBER <br /> EEE RRReEECCC 11�.v� SAN JOAOUIN COUNTY <br /> MAY 3 2011 / JL ENVIRONMENTAL HEALTH DEPARTMENT t �� <br /> � •' 1868 East Hazelton Avenue, Stockton, CA 95205-8232 <br /> ALF 7�i Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT- -60�,. i116�1 BUSINESS/AGENCY: <br /> ADDRESS: 'a5- 2, 0`' CJf %tZO'a- CITY/STATE/ZIP: _Amoy <br /> PHONE(1): - ' - PHONE(2): FAX OR E-MAIL: M 1�L.0 t1 12 At 9 �t. <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 /> „ ', li ., : ..L.' fry _.nD 1N,. Y0, <br /> SIGNATURE OF APPLICANT DATE SI2 /(�- <br /> 1. List up to ton addresses in the spa a below. Select the types)of files from the list below by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(209)464-0135 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 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$139 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM•5:00PM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List❑ Map—Description: <br /> Specific Date Range of information Requested: From t f fo 20 t <br /> N IOU�'rF' <br /> FILE ADDRESS EHD USE ONLY <br /> U UNDERGROUND TANK(UST) street Street Name city c <br /> CLEANUP STE(LOP) H [ — / <br /> OTHER CLEANUP SITE(NON-LOP) tlt11V LA?,.L � umcn <br /> ®HA7AI1DOUS WASTE /] yT ��-�fdbp ❑DAN <br /> ®TIERED PFAMITTED FACILITY d t�LLG 4° M ���� 1 /V✓ NI), <br /> ABOVEGROUND TANK ,N ,I PWS <br /> USY (MUNI'lOWNG/REMOJAL) • • • N O®MA2ARDOUS MATERIALS a `��1� � ( V(\j:.I{ \�.1�.�1 AJO 1 <br /> SPILL/RELEAEE RESPONSE 0 I ATEc Quinn. <br /> ®SOLID WASTE FACILITY/VEHICLE d l - I ,� y,�m ry 00 td� ( J <br /> rl FOOD FACILm' t 81p1 �- ��„-'1" e� <br /> ❑POOL SPA p P� '/ � 1 NlTwanoN <br /> ❑DAIRY B �BSU l+J CS� 4x1 C J4VJc-b!J0 U ❑Y WAI ? <br /> []LAND UOEAPPLIwitON SUES /� Houaw <br /> r-1SEPTICPUUPE0.TRUCK/ S YARD/CHEMICAL TOILETS JVv v—J'(� — `��'��• , -v <br /> ❑WASTEWATERTREATMENT PLANT CUPA <br /> ❑HOUSING ABATEMENT 7 <br /> ❑MOTEL/HOTEL <br /> ❑CHICKEN RANCH/DOG KENNEL CUPA-UST <br /> ❑MEDICAL WASTE FACILITY a <br /> ❑TATTOO/BODY PIERCING 19.CLIO WASTE <br /> 0 WASTE TIRE <br /> F a <br /> COMPLAINT <br /> ❑OTHER(PLEASE SPECIFY): A.UNTINO <br /> �D <br /> A"BOXED AREA•EHD USE OPlLY" <br /> (a l w.t8. f�, f�- <br /> Cp Q31 ,I 1tQi <br /> 11 lA 0 <br /> ❑ Records provided by Staff-PPR Complete.SMff Name: — /�/ c 1 C-Q <br /> Received Time=May, 23, =2017-11 : 07ANFNo, 1558 <br />