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DATE-RECEIVED EHD LOG NUMBER <br /> 1 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT t '� <br /> 11F( 2 `? 6 i5 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ° <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: vvvvvv.sjgov.org/ehd <br /> L <br /> PUBLIC RECORDS RELEASE APPLICATI �d <br /> APPLICANT: At-1 `" BUSINESS/AGENCY: 1 <br /> ADDRESS: U'q(' C4-c_ 4,—�..� CITY/STATE/ZIP:�.��,=,,fes u"r''t k .f I tr • �.��t <br /> PHONE (1):('7 -1/-) ✓ ✓' c!-7 y(�,- PHONE (2): FAX OR <br /> r�ieasC`ailoVv 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-$130 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT �/ DATE <br /> Electronic information: ❑ List E] Map—Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street w Street Name City <br /> R_ FIC E%e-4-ICA"I C'r 4,. '? <br /> ❑ Unit 1 <br /> 2. <br /> 3. 51/unit 2 <br /> 4. D-10nit 2H <br /> S' Gnit 3 <br /> F. r� <br /> Unit 3HM v <br /> 7. <br /> nit 4 <br /> 8. <br /> SITE MITIGATION <br /> 9. <br /> 10. q �F 5, °"'t5 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> [UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ElMOTELIHOTEL ❑SOLID WASTE FACILITYNEHICLE <br /> ©OTHER CLEANUP SITE(NON-LOP) �IOUSING ABATEMENT ❑FOOD FACILITY <br /> D't1NDERGROUND TANK(MONITORINGIREMOVAL) S�rASTE TIRE ❑DAIRY,POOLISPA <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL RWASTEWATER TREATMENT PLANT <br /> HrAZARDOUS WASTE ❑MEDICAL WASTE FACILITY ❑PUMPER T RUCKIYARD/CHEMICAL TOILETS <br /> AZARDOUS MATERIALS ❑TATTOOIBODY PIERCING ❑LAND USE APPLICATION SITES <br /> ❑TIERED PERMITTED FACILITY ❑COMPLAINTIRESPONSE RECORDS ®OTHER(PLEASE SPECIFY) ''t� <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <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.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 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$130 deposit prior to review. <br /> ***BOXED AREA-EHD USE ONLY''`* <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br />