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• EHD LOG NUMBER <br /> DATE RECEIVED SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 .E <br /> elephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: �t C �� `e BUSINESSIAGENCY: <br /> ADDRESS: A.V . CITY/STATE/ZIP: <br /> PHONE(1): 2o�0H% 5-?--7f7 PHONE(2):-&g FACSIMILE: ZO <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 /> ❑CHECK BOX TO EXPEDITE REQUEST-$13 EE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BU IN SS DAYS <br /> SIGNATURE OF APPLICANT 'b-�e' DATE <br /> Electronic Information- ❑ List❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name city <br /> 1. 235(e <br /> 5- <br /> 2. <br /> 2. SGIa S. v-rite- <Cl�rrbc-([ AIFf ❑Unit1 <br /> 3. ��E' � Re(• nn Ate\\,ww�ev�wl n� a�ean�t,'54 it 2 <br /> 9A� 4. 23 P t /✓ ' ❑Unit 2H <br /> /y 5. 12gZ eG C (eISSOGn Com? LOCk� -1N t <br /> I z z B(UskDV-- G <br /> 7. � f f. g� LJr-'t M� nit <br /> q to FX C�(.V, Lo C.`'c �'d 'E" 4✓ >w(' i A IN ' <br /> g. /1, LOIC— e_/ d (y5� <br /> r� 0. I glS l¢Z lI . L�-+.ZV pV FT6ctC4 W M 5 Wb'['C0 nits <br /> qtr Specific Date Range of Information Requested: From 1 to <br /> a� 4L ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 'G <br /> fA <br /> [:]SOLID WASTE FACILITYNEHICLE <br /> THER CLEANUP SITE(NON•LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> NDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY E]DAIRY <br /> BovEGR0UN0 TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> AZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCK/YARD/CHEMICAL TOILETS <br /> ❑TIERED PERMITTED FACILITY .POOL/SPA ❑/AND USE APPLICATION SITES /rp <br /> ❑TATTOOIBODY PIERCING CBMPLAINTIRESPONsE RECORDS gOTHER(PLEASESPECIFY) 1NN�11 <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILA LE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List uD 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.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. *",BOXED AREA.EHD USE ONLY*" <br /> Y10 re(/ f R/ [oma ua C u 11415 C'/ 3 ( -e far I ' (00011,67 an l <br /> (O 17 {kaz 11 L/ l' W r I ILI 7j7) r-t 4n fl L7uw-0 <br /> 01^Q X40- wL-k A r-0. Nvtiael, LA ST 11 Ib(�le21k fS CO. AruAIl � <br /> r 124 1 ( <br /> �12v� 44 It <br /> El Records provided by tall-PPR C let . staff Name: <br /> nu+s <br /> EMD de-06 <br />