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DATE RFJ e.i- EHD LOG NUMBER <br />SIVE® �` SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />APR 2 9 2014 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />ENvPFRMITISER CSL PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: Ke N \j 1,(- K19 P� A BUSINESSIAGENCY: <br />ADDRESS: oC Li < CITY/STATEIZIP: <br />PHONE(1): PHONE(2): FACSIMILE: <br />TENTATIVE* APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application submittal -`Tentative only -must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEir ��- FEE (CASH OR CHECKO EQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICAN;,r-d-� DATE a'ZV <br />Electronic information: ❑ List E] Map -Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />/it1 <br />Sl reet# <br />Street Name <br />City <br />1. <br />og q <br />W • F} 12 ) C <br />c <br />1 mM ( L <br />u I NG MA A 3,D/hG nit 2 <br />2. <br />3. <br />0 -Unit 3 <br />4. <br />E ].tlnit 4 <br />6. <br />7. <br />tJ w <br />❑ Unit 5 <br />8. <br />9. <br />.LSI Unit 6 <br />10. <br />Specific Date Range of Information Requested: From 10 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES rrr�q..,,,,,, <br />® UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY OLID WASTE FACILITY EHICLFr <br />R1 OTHER CLEANUP SITE (NON -LOP) ❑HOUSING ABATEMENT WASTE TIRE & 5'plS �(-' 1p, <br />UNDERGROUND TANK(MONITORINGIREMOVAL�-- ®FOOD FACILITY ❑DAIRY. P2. 5-Fl- <br />�, ABOVEGROUND TANK O�_ ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER TREATMENT PLANT <br />HAZARDOUS WASTE/HAZARDOUS MATERIAL ❑MOTELIHOTEL ❑ PUMPER TRUCKNARDICHEMICAL TOILETS <br />TIERED PERMITTED FACILITY ❑-POOLISPA ❑ LAND USE APPLICATION SITES <br />] TATTOO/BODY PIERCING WOMPLAINTIRESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <br />WELLAND 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. Select the type(s) of files from the list above by checkingthe 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 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 expense of the <br />Future file reviews by the same applicant may require a $125 deposit prior to review, "BOXED AREA- EH <br />I ❑ Records provided by Staff -PPR Complete. SfaffName: <br />