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i <br /> ,-., EHD LOG NUMBERfV <br /> �`,V, „f SAN JOAQUIN COUNTY <br /> ,)01. 2 4 2014 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ENVIRONMElephone: (209) 468-3420 Fax: (209) 464-0938 Web: www.sjgov.org/ehd <br /> iji-- I--TH DEPARTMENT <br /> PUBLIC RECORDS RELEASE APPLICATION On F F W <br /> APPLICANT: BUSINESS/AGENCY: nn <br /> ADDRESS: !U, I�`Yl CITYISTATEIZIP: C 52 V <br /> PHONE{1}: q PHONE {2}:_ l1? , <br /> TE ATIVE*APPOINTMENT DATE: . _ Time: <br /> (Please allow 10 business days from date of application submittal-"Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT' DATE <br /> Electronic Information: ❑ List❑ Map--Description: -_ <br /> FILE ADDRESS ErID USE ONLY <br /> Street;i Street Name City ❑Unit 1 <br /> 2. ` [j Unit 2 <br /> 3. <br /> 4. ❑Unit 3 <br /> 5. <br /> 6. ❑Unit4 <br /> 7. <br /> $. ❑Unit 5 <br /> 8. <br /> 10. ❑unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYIVEHICLE <br /> OTHER CLEANUP SITE(NON-LDP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCHI DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ❑HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES n ►i� � <br /> ❑TATTOOIBODY PIERCING ❑COMPLAINT/RESPONSE RECORDS DTH ER(PLEASE SPECIFY) 1"9- `r /.,��e <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDA7YlS))! <br /> 1. List up 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 file addresses,contact the EHD. Applications received after =1 <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. L <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. 4 <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 /> j "� - I2? <br /> b. ecords provi ed b t -' PR :o plete. Staff am : ' <br /> EHD 48-06 r i I f P ' r ® C fYI cAd i 4 A ti!1 tz <br />