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EHD LOG NUMBER <br /> rD E EJB =i SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT f4 <br /> • DEC 10 2415 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> ENIVIRONIMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: )0 V &A A G LE i BUSINESS/AGENCY: T-TN T T � �Ct'F C'-F.O 'P, /a`C <br /> ADDRESS: �� s4 >I S�(e2't CITY/STATE/ZIP: 4,��rL2 <br /> PHONE (1): P{t, y''X,5-6yo PHONE(2): N5lr 3 5. G f Y FAX OR E-MAIL: ° J E S CL�..✓!t �' <br /> Please allow 10 business days from date of application submittal for the records to ' vailab! . <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REQUE $13 CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT �!'r�✓ DATE <br /> Electronic Information: E� dsst ❑ Map—Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street# Street Name ( City <br /> 1. Cih5 C •T CIA.-1-0, WAY J ❑ unit 1 <br /> 2. <br /> 3. � nit 2 <br /> 4. l _ <br /> El unit 2H <br /> s. � CS l5y[niit�t3 f2lj0 <br /> 6. , . � Unt 311M• 7. &S�G, ` WAY nit4 <br /> 8SITE MITIGATION <br /> 91�/-t5 <br /> 10. or <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MOTELIHOTEL ISI SOLID WASTE FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT LFJ,FOOD FACILITY <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑WASTE TIRE ❑DAIRY,POOL/SPA <br /> ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL WASTEWATER TREATMENT PLANT <br /> HAZARDOUSWASTE ❑MEDICAL WASTE FACILITY PUMPER TRUCK[YARDICHEMICAL TOILETS <br /> HAZARDOUS MATERIALS F]TATTOOIBODY PIERCING ❑LAND USE APPLICATION SITE'SAI/ ' <br /> TIERED PERMITTED FACILITY ❑COMPLAINTIRESPONSE RECORDS PSOTHER(PLEASESPECIFY) vV`HI/L�rCNI1� <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW' MONDAY-FRIDAY 8:00 AM-5:00PM(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)484-0138 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 /> • <br /> 0 Records provided by Staff-PPR Complete. Staff Name: <br />