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At Advanced GeoEnviroji'": (707) 570-1461 ITo: Fax: +1 (209) 464-0138 Page 1 of 1 12/04/2015 3:47 PM <br />EHD LOG NUMBER <br />■ DATE RECEIVED <br />, ..� y� SRN.IOAQUIN COUNTY 1,/ <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />■ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 (/ <br />DEC 0 7 Z015 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />EIVARON`MENTAL HE.LYK <br />PERfrhIT/sEWICIE�' PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: R,=hF.r Natal BUSINESSiAGENCY: ArivAnnar) fiPr)I-n\/I rr1 nYTlPr tai <br />ADDRESS: A37 I;h;;w Road CITY/STATEIZIP: Stnrktnn / CA / 9571.5 <br />PHONE (1): 209-467-1006 PHONE (2): FACSIMILE: 209-467-1118 <br />TENTAT/VE'APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application submittal-"Tenradve only - must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST- $125 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT <br />DA <br />Electronic Information: ❑ List ❑ Map - Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />D Unit 1 <br />Street # <br />Street Name <br />City <br />1. <br />UFt <br />Q�lt 2 <br />rion <br />Fn -,t I nijisp Ayp <br />I athrop_ <br />3. <br />r.pwn)lrop_ <br />uiti, f 3 tr <br />nit 3 <br />4. <br />5. <br />n / <br />a4 <br />) nR5 <br />8. <br />9. <br />�)� IVtifi <br />10. <br />Specific Date Range of Information Requested: From all to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />x❑ UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT Z SOLID WASTE FACILRYNEHCLE <br />x❑ OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑X WASTE TIRE <br />x❑ UNDERGROUND TANK (MONITORING(REMOVAL) ❑ DOG KENNEL Q DAIRY <br />Q HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ WASTEWATER TREATMENT PLANT <br />x❑ TIERED PERMITTED FACILITY ❑ MOTEUHOTEL ❑ PUMPER TRUCK/YARD/CHEMICAL TOILETS <br />❑ TATTOOBODY PIERCING ❑ POOUSPA Q LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY [] COMPLAINT 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. 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 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 appolntmentfor 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. AFIe 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 applicant. <br />-- _ Future file reviews by the same applicant may require a $125 deposit prior to review. <br />' Lo k Ccs 1 a a2V Qc lar C90 L.9a lb h <br />T ,ek CO ';-90 LAve. <br />Received Time Dec. 4. 201 ' 3:47�o.0128 811111 <br />