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1 11111 MU//Zi/2014 WED 15: 9` FAX 209923t3960 Cannon C9075 I�OQ1/001 <br /> 1 ■ <br /> �Nn <br /> l i � B' 1111111)LOG NUMBER <br /> ■ VED SAN JOAQUIN COUNTN <br /> ■ ENVIRONMENTAL HEALTH DEPARTMENT " k•�. <br /> JUL 2 3 2014 <br /> 1868 Fast Hazelton Avenue, Stbckton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www-sjgov.org/ehd <br /> ENVIRONMENTAL HEAL to <br /> PFPnnIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> .;` :.:i •:' yam.� .� <br /> APPLICANT: G1 0� MAY lzA -, 4&m� m �yjY eYADUSINESS/AGENCY: G <br /> ADDRESS: QQ .6 yaf ': CITY/STATE/ZIP: avkGa F bk a5!S6 to <br /> PHONE(1): PHONE(2): 14,5 jp -IK()11) FACSIMILE: qit D <br /> Please 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 /> 2/CHECK BOX TO EXPEDITE REQUEST-$125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT-(".. �Ly�a t `�" '' Lel " - DATE <br /> Electronic Information: 9LIst❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street 6 Stnret Name city Unit jr,' <br /> 6L �' [I Unit 2 <br /> 3. �- a. . r Z'i�c: r <br /> 4. ,� � �.: ti oi✓) N 0 ` unit a <br /> 6. <br /> 6. Unit 4 <br /> 7. <br /> ❑unit e <br /> e. <br /> 10. unit 6 <br /> Specific Date Range of information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> Q UNDER©ROUND TANK(UST)CLEANUP SITE(LOP) E]MEDICAL WASTE FACILITY SOLID WASTE FACIL TyIVEHI LE <br /> [ BOTHER CLEANUP SITE(NON-LOP) ❑HOUSING A9ATEMENT ❑WASTE TIRE �j TIPS�,- <br /> UNDERGROUND TANK(MONITORINGIREMOVAL)b( ❑FOOD FACILITY ❑DAIRY F"—' •7-M-1� <br /> BOVEGROUND TANK,A ❑CHICKEN RANCH/D00 KENNEL ❑WASTEWATER TREATMENT PLANT <br /> YHA7ARDOUS INASTENAZARDOUS MATERIALS)_ ❑MOTELIHOTEL ❑PUMPER TRUCKIYARD/CHEMICAL TOILETS <br /> ❑TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND U9EAPPLMATION SITES <br /> ❑TATTOo1BODY PIERCING ❑COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 Ann-6:00PM(EXCLUDING HOLIDAY$) <br /> 1. List un to ten addresses in the space above. Select the typo(s)of flies from the list above by checking the appropriate <br /> boz(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail tsr,lihe address indicated abovQ. Address, <br /> ranges will not be accepted.Applications received 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.filips exist. An appointment for review will be confirmed approximately ten(10) <br /> days after receipt of application. The flies will be held for a maximum of five business days for review. Appointments <br /> should be scheduled accordingly. <br /> A. Any file not returned In the same condition as released will be reorganized by EFID staff at the expense of the applicAnt. <br /> Future file reviews by the same applicant may require a$126 deposit prior to review. '"BOXED AREA-EHD USE QNi- <br /> 7 Z�"l 7 0d L rn� SCS UCG ' <br /> Mp (10110tA) 7q 14 <br /> r SID(od 5�Z <!� ti; !� '00 L(->(o r S v ` - -O� U(2) <br /> 11-Re aff-PPR CompletGr Ste# : w j')o ?7-it <br /> eNo 4MO <br /> Received Time Jul, 23. 2014 3: 06PM No. 6670 <br />