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03/25/2013 09:39 FAX 4001
<br /> EHD LOG NUMBER
<br /> DATE RECEIVED SAN JOAQUIN COUNTY
<br /> CI
<br /> ENVIRONMENTAL HEALTH DEPARTMENT
<br /> Stockton, CA 95205-6232
<br /> �i 1868 East Hazelton Avenue, n
<br /> BAR 7TH phone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd 0`
<br /> ,r�,Atagr�, � 4, ��' UBLIC RECORDS RELEASE APPLICATION
<br /> APPLIC 1AA\ n BUSINESSIAGENCY: ?0110 r A
<br /> ADDRESS: s61 W aft . 1J11,1oa>r CITYISTATEIZIP: Ca�_(Gh
<br /> PH09E(1): PHONE (2): (,�i�'3$ '� '.f FACSIMILE:
<br /> TEN TIVE"APPOINTMENTDATE:. Time: 9�15a�ftiL-
<br /> (Please allow ID business days from data of applibation submittal-•Tentative only-must be confirmed)
<br /> ❑CHECK BOX TO EXPEDITE REQUEST-$1 FEE ASH O HECK ONt.Y)-REQUEST PROCESSED INS BUSINESS DAYS
<br /> SIGNATURE OF APPLICANT DATE 3 2g 13
<br /> Electronic Information: ❑ List❑ Map Descrip on:
<br /> FILE ADDRESS . EHD USE ONLY
<br /> Street 9 Street Name City ❑unit 7
<br /> 2. N a (50 CQ 2g 352 5 G Y) El Unit 2
<br /> 3• 423 Madison an
<br /> d 420 Madison
<br /> 4• . Historic reports . , CYta 2611-113
<br /> 5. Any boring logs in the files 7r�dILS �°/td r^/ l
<br /> 6. Well installation reports
<br /> Soil investigation reports
<br /> 7• a Groundwater investigation reports Li �J 13?
<br /> S. . UST removal reports l J ❑Unit s
<br /> 9. . Groundwater monitoring reports
<br /> 10. ❑Unit s
<br /> Specific Date Range of Information Requested: From 1=4CilP�t to 2005
<br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES
<br /> ®UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLA)WASTE FACRmfVEHICLE
<br /> ®OTHER CLEANUP SITE(BION-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE
<br /> ®UNDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FAC3LrFY ❑DAIRY
<br /> ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT
<br /> HAZARDOUS WAsTEMA7AROous MATERIALS ❑MOTEL/HOTEL ❑PUMPER TRUCKfYARD/CHEMICALTOILETS
<br /> ❑TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES
<br /> ❑TATTOOIBODY PIERCING ❑COMPLAINTIRESPONSE RECORDS OTHER(PLEASE SPECIFY) Pt%,W
<br /> WELL AND SEPTIC PERidi1T RECORDS ARE AVAILABLE FOR REyIEw: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS)
<br /> 1. List un 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(200)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 behold for a maximum of five business days for review. Appointments
<br /> should be scheduled accordingly.
<br /> 3. A file that Is actively being worked on by EHD staff may not be Immediately available for review. A new 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$125 deposit prior to review. YxiO( 3 EFIl3U$ :}IL
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<br /> Received Time Mar, 25. 2013 9� 36AM No. 2627 9141121
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