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I%0 <br /> 0Dec 08 2015 12: 30PM _ P. 1 <br /> EHD LOG NUMBER <br /> l� `bACEf2EC£IVEF� �; ar7s <br /> SAN OA.QUIN CoU"> T <br /> M5ENVIRC)NMENTAL-HE'ALTH DEPARTMENT - <br /> "DEC 0, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 46873420 Fax. (209) 464-0138 tl`tfeb:wWw.sjgcv.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> tiAPPLICANT: C ko rA L_ A'n&,Go-- -- -EtlS114E9S1AGEFICY: L <br /> ADDRESS: _ ZG I t] Cc uLd �,'d"n40,\ -)P}. I_"�{ (�'C? CITYrSTATE2IP: " �fa i, <br /> PHONE(1): 2C�1 �g 14 ��� " PHONr=(2)� q ��- 3a1 327--' FAX o� E-MAIL: �!9Cw%601 00 envza,C <br /> k Please allow 10 business days from date of application submittal for the records to ailable. <br />` Staff will contact you to arrange an appointment date and time to review the requested records. <br /> __ [1 1.[:.T.L:Ifl Rrll 31 3� Sri {xT"�3 4g� ^l.Fi !"+. y •R. M'�^ f�y' <br /> SIGNATURE OF APPLICANT V !]ATE <br /> Electronic Information: ❑ List Map—Description: <br /> FILE ADDRESS <br /> Elio USE ANL)' <br /> Street Street Nsme city <br /> 1. .5OI 02- G r Ot J`tr+ h <br /> i 2. 30-3 <br /> t 1 1� IVl F ❑unit I <br /> l 3' q1 -3 ❑ Unft2 <br /> 4. l 1 1 ❑ Unit 2H l rJ <br /> Fs (ZjV'1 ek ©u'nit 3.1 <br /> f <br /> ®Un1t3HM <br />} 7. I . <br /> 1�.'I�'l O• ®�nit4 <br /> [--3�SITEfarnr3ATION" <br /> S. <br /> �jQ ❑units <br /> Specific Date Range of Information Requested: From to <br /> MIND ERGROUND TANK(LIST)CLEAN UP SITE(LOP) ❑IIIIOTELIHOTEL ❑SOLID WASTE FACEtTYNEHICLE <br /> 21ITHER CLEANUP SITE(KION-LOP) ❑HOUSING ABATEMENT ❑FOOD FACILITY <br /> Ii NDEAGROUND TANK(MONITORINGIREMOUAL) ❑WASTE TIRE ❑DAIRY,POOLISPA <br /> AAsOYEGROUND TANK ❑CHICKEN RANCH/DOG"KENNEL ❑WASTEWATER TREATMENT PLANT <br /> II HAZARDOUS WASTE ❑MEDICAL WASTE FACILITY ❑PLIMPER TRUCK/YARD/CHEMICAL TOILETS <br /> La <br /> HAZARDOUS MATERIALS ❑TATTOO/BODY PIERCING ❑LAND t15E APPLICATION SITES <br /> i ❑TIERED PERMITTED FACILITY . ❑COMPLAINTIRESPONSE RECORDS ❑OTFIER(PLEASE SPECIFY) <br /> WELLAND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: IVIONDAY•FRIDAY 8:00AM-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List up to ten addresses In the space above. Select the type(s)of flies from the list above by checking the appropriate <br /> box(es). At feast one file type MUST be selected. Fax to(2091464-0138 or-Mail to the address indicated above Address <br /> ranges will not be accepted.Applications received after 3:00 pm wHi 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 /> 6- Anv.flle riot returned Fn the tame cen`iirion are released Vairll h4 .e..,.,..:, a�..a r. a_�r <br /> •.•-gani—zed. ,y EVID oaoi_c atthe fKXPense ai the appiicanL <br /> Future fife reviews by the same applicantmay reouire a 5130 deposit prior to review. <br />{ —BOXED AREA-1=HD USE ONLY— <br /> a <br /> 1 <br /> 113 Record <br /> s pmvfded b Staff-RPR ComTiplete. staff Name: " <br /> I <br />{ <br /> 1 Received Tune Dec. 8. .2015 11 : 29AM No. 0158 <br /> t <br /> I <br />