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Ah SAN JOAQUIN COUNTY d& <br /> RECEIVE® ENMONMENTAL HEALTH DEPARTf i�t�T . <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> NOU <br /> 19 2012Telephone: (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> c �nn t ` P n <br /> APPLICANT: �Vb I�ac Lx BUSINESS!AGENCY: L.tarwLr, Ca�Unvirm,w�^� Y <br /> ADDRESS: CITY)STATE(ZIP: LmRa , CA 4 C 2,-4 a <br /> PHONE (1): PHONE(2). 3>,pV-32:41. FACSIMILE: 3(fl`/-03_f'i- <br /> TENTATIVE`APPOINTMENT DATE: t Z - 4 - I -L- Time: t o : 2a <br /> (Please allow 10 business days from date of application VAXnNffiI-"rerNatrveonlY-must be connrmed) <br /> ❑CHECK BOX TO EXPEDITE REQU -$125 (CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT IGIVA DATE r t ` 11 -1 -2- <br /> Electronic <br /> 1 `12Electronic Information: ❑ List❑ Map-Descfipti6n: <br /> FILE ADDRESS EHD USE ONLY <br /> street* Street Name City L3 unit 1 <br /> [44. <br /> LtaWS� S . 3 <br /> 2� ❑Unit 2 <br /> Unit 3. <br /> 6. 1 jle ID unit 4 <br /> 7. <br /> g, untt 5 <br /> 8. <br /> 10. units <br /> Speolflo Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES —I <br /> UNDERGROUND TANK(UST)CLEANUP SnE(LOP) ❑MEDICAL WASTE FACILITY D SotaD WASTE FAcLiTYNEHICIE <br /> OTHER CLEANUP SIT E(NON-LOP) ❑}IousiNGA8ATEMENT ❑wAsrETmE <br /> UNDERGROUND TANK(MONRORINGIRE1110VAL) ❑FOOD FACILITY ❑DAIRY <br /> MABOVEGROUND TANK ❑CHICKEN RANCHi Ow KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOus WASTEM"fi MUS MATUOALs ❑MOTEUHOTEL ❑PUMPER TRUCKNARDICHEMICALTouTs <br /> TIERED PERMITTED FACILTIY ❑POOUSPA ❑LAND USE APPLICATION SITES <br /> TATTOO(BODY PIERCING &COMPLAtwIRESPONSE RECORDS []OTHER(RRASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AmS:DOPM(EXCLUDING HOLIDAYS) <br /> 1. List up jq ten addresses in the space Above. Select the type(s)of fifes from the list above by checking the appropriate <br /> box(es). At least one file type MUST be aefected. Fax to(2091464-0130 or mall to the addnias Indicated above. Address <br /> ranges will not be accepted-for additional assistance with file addressee,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 approxlmaWy tan(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 FID staff may not be immedlafely available for review. A new application may be <br /> submitted when the file Is available. <br /> 4. Any file not returned in the some condition as released will be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviews by the some applicant may require a$125 deposit prior to review. *'BOXED AREA-EHD USE ONLY <br /> ❑ Records nrovlded bV Staff-PPR Complete. staff Name; �an2 <br /> Received Time—Nov, 19. -2012-11 :56AWNo, 1662 <br />