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SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> JAN 0 9 2017t� ENVIRONMENTAL HEALTH DEPARTMENT q53;jq <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 <br /> @AMltONMEKALHF„AM Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sigov.org/ehd <br /> PEfAMRrWcRVECM ` PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: IL 0"n'rf( BUSINESS/AGENCY: <br /> ADDRESS: ,32[`j77,� (�iir,Jq Gl^"t y' CrrY/STATE2IP:...l." _. /._- <br /> PHONE(1): !210 Y,3T S Z l( PHON (2): FAX OR E-MA L '64-4' <br /> ry Z" 'Yy Please �- <br /> 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-$139 EFE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE i/q/17 <br /> 1. List up to ten addresses in the space below. a types)of files from the IIsi below by checking the appropriate <br /> box(es). At least one file type MUST be Bele e x to 209 464•D138 or mail to the address indicated above. Address <br /> ranges will not be accepted.Applications rec ed 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$139 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM•5:00PM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List❑ Map—Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL / U44 <br /> .,-HEALTH DEPFILEARTMENT FILE ADDRESS EHD USE ONLY <br /> pl l UNDERGROUND TANK(UST) Street N Street Name City /J 1� <br /> �a CLEANUP SITE(LOP)`�/�,�}, - h�,- IC 05;0O7i�/ ❑C�G4U/MEPs <br /> OTHER CLEANUP Srrpr 1 � � �. 1QS�, I` "FlJC� VIaVI•�C4� OO OZ2II IGlA �(.(/I�V <br /> ❑HAZARDOUS WAST NItE4�''•J�/� F� JI`�1 J-t ❑DAIRY <br /> ❑TIERED,PERMITrEED Tv`� '( <br /> ❑ASOVEGROUNeT lK��'SSSJJJIt <br /> UST (MOMTORING <br /> ❑ / pR <br /> D Pws <br /> HAZARDOUS MATER %y�/ O <br /> J <br /> SPILURELEASE RESPONSE'( <br /> ❑SOLID WASTE FACILITY/VEHICLE WATER ODFLIiv <br /> 4 <br /> ❑FOOD FACILITY <br /> ❑POOL I SPA "TE MITIGATIDN <br /> ❑DAIRY e <br /> ❑LAND USE APPLICATION SITES <br /> ❑SEPTIC PUMPER TRUCK I ❑HOUM. <br /> 6 <br /> YARD/CHEMiCAI TDILETS <br /> ❑WASTEWATER TREATMENT PLANT <br /> CUPA <br /> ❑HOUSING ABATEMENT r <br /> ❑MOTELMOTEL <br /> ❑CHICKEN RANCH I DOG KENNEL CUPA-UST <br /> ❑MEDICAL WASTE FACILITY S <br /> ❑TATTODIBODY PIERCING <br /> ❑WASTE TIRE ❑SOCIO WASTE <br /> 9 <br /> ❑COMPLAINT <br /> ❑OTHERIPLEASE SPECIFY): ALCOUMING <br /> 10 <br /> ^`BOXED AREA-EHD USE ONLY— <br /> IF vl` <br /> ❑ Records provided by Staff-PPR Complete. staff Name: <br /> EHD 4M6 <br />