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f'�A�L�E 'EGO V "D <br />!MNTY <br />SAN <br />JUL 17 2014 ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />-T L hone: (209) 468-3420 Fax: (209) 464-0138 Web: www sjgov org/ehd <br />ENVIRONMENTAL H AeL <br />PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: �>jat j 4j j 1�10�j S.4 .J"'' S - BUSINESS/AGENCY: � M <br />ADDRESS: _ 7 c �, iVC CITY/STATE/ZIP: WISAI(A- Cy."0-, C44 �(`JSri -7 <br />PHONE (1): 01 7S `f '�-' ' U d PHONE (2):57 SA, U!; , t--r1y? FACSIMILE: <br />I <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 />CHECK BOX TO EXPEDITE REQUEST - $125 FEE (CASH OR CHECK ONLY) -REQUEST PROCESSED IN,3 BUSINESS DAYS <br />cir°k�inTi1oO ^F nDDI <br />IZA t"N' `Z-�.-..f" -DATE <br />VIV Vb.L <br />Electronic Information: ❑ List ❑ Map- Description: 4 f ; , I , , 1 i i ' "' L -"!, _ . / / / 4 <br />FILE ADDRESS <br />C�v <br />(-Y <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />E UN ERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE FACILITYIVEHICLE 1� 0144 7 <br />THER CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT ❑ WASTE TIRE <br />W DERGROUND TANK (MONITORINGIREMOVAL) ❑ FOOD FACILITY ❑ DAIRY 1-7, �1 } <br />-1 ABOVEGROUND TANK ❑ CHICKEN RANCHI DOG KENNEL []WASTEWATER TREATMENT PLANT 11 <br />❑ HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑ MOTELMOTEL ❑ PUMPER TRUCKIYARDICHEMICALTOILETS <br />❑ TIERED PERMITTED FACILITY ❑ P OLISPA ❑ LAND USE APPLICATION SITES <br />❑ TATTOO/BODY PIERCING ❑/ COMPLAINT/RESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <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 $125 deposit prior to review. '`**BOXED AREA - EHD USE ONLY*** <br />4W -6 LOCA -JLW �015eA, +''Vyir:�-� CO c� XM s>7ir»scan �i�� .nJtak�� 50� AlrPo�# US <br />M023itpgl 4- K056307, & 7ton Atr pF rt - usr ,nshQif , ?r_02.31(aqi sio^iietl & 50o:� .414rd- <br />N i pOl <br />A. <br />Street# <br />Street Name <br />City <br />/ <br />itL - '"'}i <br />L tl L�%�r-t t FYI Ca J <br />" <br />2. I <br />3. <br />�r� (0 <br />S bbl e✓4' <br />�-� .j0 ,n. 1U 0 <br />c �k-►,. F <br />dt't ' �Fe <br />5r N�^M <br />I U5T5TM <br />csf� <br />Co' <br />[0/Unit 3 <br />4. ZG•rJ <br />5 <br />j:� <br />' s. v I ti W' <br />f G z <br />N 1 Pa u►u•} <br />Cs�S <br />6.❑�lUnit4 <br />7. <br />"! t O 3521 <br />❑ Unit 5 <br />❑ Unit 6 <br />9. <br />10. <br />(-Y <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />E UN ERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE FACILITYIVEHICLE 1� 0144 7 <br />THER CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT ❑ WASTE TIRE <br />W DERGROUND TANK (MONITORINGIREMOVAL) ❑ FOOD FACILITY ❑ DAIRY 1-7, �1 } <br />-1 ABOVEGROUND TANK ❑ CHICKEN RANCHI DOG KENNEL []WASTEWATER TREATMENT PLANT 11 <br />❑ HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑ MOTELMOTEL ❑ PUMPER TRUCKIYARDICHEMICALTOILETS <br />❑ TIERED PERMITTED FACILITY ❑ P OLISPA ❑ LAND USE APPLICATION SITES <br />❑ TATTOO/BODY PIERCING ❑/ COMPLAINT/RESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <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 $125 deposit prior to review. '`**BOXED AREA - EHD USE ONLY*** <br />4W -6 LOCA -JLW �015eA, +''Vyir:�-� CO c� XM s>7ir»scan �i�� .nJtak�� 50� AlrPo�# US <br />M023itpgl 4- K056307, & 7ton Atr pF rt - usr ,nshQif , ?r_02.31(aqi sio^iietl & 50o:� .414rd- <br />N i pOl <br />A. <br />