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DATEECEIVE EHD LOG NUMBER <br /> ,✓ /s SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> JTelephone: (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd j <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: anmjsa ffia,(A-'In-e, BUSINESSIAGENCY: �A. �)ent. of <br /> ADDRESS: �(j �, � ( �aj��J� • CITY/STATEI2IP:�L)(�r,+ 9,Cfn np vlo cllI /am <br /> PHONE(1): (21 0 a7 0-9-l3 PFt6NE (3): �i t mar+v �� FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: 3� 1 }I L) c Time: ]O.'0DaAof) <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE RE VEST-$124,FEE(CASH OR C CK ONLY)-REQUEST PROCESSED IN 3 BUtSINE�jS DAYS <br /> SIGNATURE OF APPLICANT DATE o2'f`aU 1]y <br /> Electronic Information: QList❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> I(� Street# Street Name City ❑VnIt 1 <br /> 1. 16L11 W s� W m� , ND <br /> 2. 1 _& I ❑Unit 2 <br /> 3' a5 -bew Arve AJ Ir <br /> 4. pi /�� / <br /> C9Unit 3 / <br /> UnR4 <br /> 7. ------------ <br /> i <br /> 8. <br /> 9 ❑units <br /> 10. <br /> ❑Unit 6 <br /> Specific Date Range of Information Requested: From to Nyex j- <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACIUTYIVEHICLE <br /> OTHER CLEANUP SITE NON-LOP �3• <br /> ( } ❑HOUSING ABATEMEfIT � <br /> ❑WASTE TIRE ?' �(1jV�j'��/'I,V! <br /> UNDERGROUNO TANK(MONITORINGIREMOVAIj_ ❑FOOD FACILITY ❑DAIRY -" ':�-3r-) <br /> ABOVEGROUND TANK c,� - ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> TATTOOIBODY PIERCING atOMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORgS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> 1. List un 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 Ole 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 applicant. <br /> Future file reviews by the same applicant may require a$125 deposit prior to review, **'BOXED AREA-EHD USE ONLY*`- <br /> �L• P ' P U d Vi Q <br /> I 1 C6JnJs's n n 5(Sw <br /> ,1 <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 4MS <br /> 9!4/12 <br />