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DATE RECE• " tl EHD LOG NUMBER <br /> � - SAN JOAQUIN COUNTY <br /> J0, 2 4 2014 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �1[} ae B��a1 py'p` hone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> HEALTH H OF-P.AH T Ui,;Elt�T <br /> PUSLIC RECORDS RELEASE APPLICATION 3 <br /> 1411110%0 9- 1 <br /> APPLICANT: —G fba nT"b.A - Dei BUSINESS/AGENCY: n <br /> J��©CITY/STATEIZIP:ADDRESS: Qlm <br /> PHONE (1): .aQg� PHONE(2): FSR Com: �t_{ pJil /t' iJ/Y12, <br /> TEWATIVE*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 f- 2y_lq <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑Unit 1 <br /> F2. El <br /> ` 6 <br /> 5 IUnit 2 <br /> 3. <br /> 4 ❑Unit 3 <br /> 5. <br /> 6. ❑Unit 4 <br /> 7. <br /> 8 ❑Unit 5 <br /> 9. <br /> 10. I ElUnit 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 FACILITYNEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCH]DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ❑HAZARDOUS WASTEMAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICALTOILETS <br /> ❑TIERED PERMITTED FACILITY ❑POOL/SPA ❑LAND USE APPLICATION SITES I� <br /> COMPLAINTIRESPONSE RECORDS OTHER(PLEASE SPECIFY) 01 � �"c � <br /> ❑TATTOOIBODY PIERCING ❑ 10 1/13//Y <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8.00 AM-5:00PM(EXCLUDING HOLIDAYS)ID <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 <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 y` <br /> should be scheduled accordingly. Fes' <br /> 3. A file that is actively being worked on by EHD staff may not be immediately available for review. Anew application may be <br /> submitted when the file is available. <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. r"BOXED AREA=EHDUSE ONLYi <br /> 1-���-I<<'• f?!a:!+�� %' r!� u Jnr'; 6j. Cp,+''-!;art MA i I -Fri a;J� Mr)t—: 2 lyla O! <br /> I Oh I/i,1k Ll &r -r-4 q S. :Irr.-T 1 PJ4 . A) o 10 D'bs <br /> '11 s. ' �✓`f v : Ha /19a.7' <br /> 5 a ®t 1 i . ti Ve �6f <br /> i-a7 S! /U. 7L,Wn4On i `el.r►d c, MO)&-iTMOOO-CIA R Q a <br /> ecords provided bxtqff- PR Co plete._staff'ame: p r <br /> EHD 48-06 VA' woI i 1 Q �V `loan® ChaCI {�a4l9A01 it, <br />