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■04/15/2014 13: 06 FAX 3106154544 X001/001
<br /> I�
<br /> I ■ DATE RECMVED
<br /> ■ EHD LOG NUMPIER
<br /> SAN JOAQUIN COUNTY
<br /> '.■ E, E // I f3 ENVIRONMENTAL HEALTH DEPARTMENT "' W
<br /> R
<br /> 1868 East Hazelton Avenue, Stockton, CA 95205-5232 y `+
<br /> APR glephone: (209)468-3420 Fax: (209)464-'0139 Web: www.sjgov.org/ehd
<br /> E'NVIRONMEN:. A HEALTH PUBLIC RECORDS RELEASE APPLICATION
<br /> APPLICANT,__T' BUSINESSIAGENCY:
<br /> ADDRESS: q1711 CITYISTATEMP: 1
<br /> PHONE (1): - S PHONE (2): FACSIMILE: _
<br /> TENTr IVE*APPOINTMENT DATE: L Time:
<br /> 16
<br /> (P lease allow 10 business days from clotd of application submittal-=Tanfaffve only.must be conArmod)
<br /> ❑CHECI BOXTO EXPEDITE REQUEST-$125 FEE(CASH OR C CK ONLY)-REQUEST PROCESSED IN 3 8 SIN SS DAYS
<br /> SIGNATURE OF APPLICANT DATE (f [q
<br /> Electronic Inf9 atlon: ❑ List❑ map—Description:
<br /> FILE ADDRESS EHD USE ONLY
<br /> Street# Street Name City Unit 1
<br /> 2. '� +i
<br /> ❑Unit 2
<br /> 3
<br /> 773 1 T5 m o:sTa fip -Ac r vJ I
<br /> Y ,
<br /> Lj
<br /> 4. �Unit 3
<br /> 6.
<br /> Unit 4
<br /> 7.
<br /> 0 Unit5
<br /> 9.
<br /> 4e_
<br /> Unit 8•
<br /> Specific Date Ran a A Informatlon Requested: From to
<br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES
<br /> XUNI) Rfs'ROUND It (UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY SDL1D WASTE FAcuTYNEHICL.E
<br /> OTHER CLEANUP I (NON-LOP) ❑Housixe ABATEMENT WASTE TIRE
<br /> UNDERGROUND F (MONf DMNG/REMOVAL) ❑FOOD FACILITY DAIRY
<br /> ABOVEGROUND ❑CHICKEN RANCH/DDG KENNEL ❑WASTEWATER TREATMENT PLANT
<br /> HAZARDOUS WA E OUS MATERIALS ❑MOTEL/HOTEL ❑PUMPER TRUCK(YARDICHEMICALTOILM
<br /> R
<br /> TiERED PERPAiTT ACILITY ❑POOUSPA [jLAND UsE APPLICATION SITES
<br /> TATTooBaDY P' R wG � LAI
<br /> CONPNTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY)
<br /> WELL AND SE PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOUDAY5)
<br /> 1. Llut uio to In the space ahova. Select the type(s)of files from the Ilst above by checklnO the appropriate
<br /> box(es). At �a t one file type MUST be selected. Fax to(209)464-0138 Qr mail to the address indicated above. Address
<br /> ranges will n. t e accepted-for additional assistance with flie addresses,contact the EHD. Applications received after
<br /> 3:00 pm will lbe processed the next business day.
<br /> 2. The EHD will nc tifythe applicant if any EHD files exist An appointment for review will be confirmed approximately ten(10)
<br /> days after e t of application, The flies will be held for a maximum of five business days for review. Appointments
<br /> should be zc�e duled accordingly.
<br /> 3. A file that Is ac the y being worked on by EHD staff may not be immediately available for review. A new application may be
<br /> submitted w e i the file Is available,
<br /> 4. Arty file not r t rned In the some condition as released will b-a reorganized by EHD staff at the expense of the-aIlp cant.T
<br /> Future file re 1 ws by the same applicant may require a$125 deposit prior to review. t-,QQXE FALSE ONV m
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<br /> Received Time AP r. 16. 2014 1 : 16PM No, 5793
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