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04/15/2014 14:19 83133836 SINCERELY YOURS PAGE 01/01
<br /> ■
<br /> �■ DATE RECEIVED
<br /> EHD LOG NUMBS
<br /> ;■ SAN JOAQUIN COUNTY
<br /> ENVIRONMENTAL.HEALTH DEPARTMENT
<br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232
<br /> ,,,,,Te
<br /> P,,,�®I�ephone: (209)46&3424_Fax: (209)464-0138 Web: www,sjgov.org/ehd
<br /> ELIC RECORDS RELEASE APPLICATION
<br /> APPL E®tl111'CIq`6� ,
<br /> ' r&Lse BUSINESS/AGENCY: VG.!-
<br /> ADDRESS:
<br /> -,S_/ Pv`t�.d17, CITY/STATEIZiP: ~e-¢
<br /> PHONE(1): �� 2- �}�PHONE 2): FACSIMILE: ^1
<br /> TENTATIVE*APPOINTMENT DATE_ Z TImQ;
<br /> (Please allow 10 business days from data of applicati 'sub ictal-`TeRf0five only-must be ca- rmm
<br /> C] CHECK BOX TO EXPEDITE REQUEST-$125 FEE(CAS ONLY)-REQUEST PRDCESSED�INS UU NES DAYS
<br /> SIGNATURE OF APPLICANT DATE ( l
<br /> Electronlc Information: ❑ List 0 Map-C) Ion:
<br /> FILE ADDRESS END USE ONLY
<br /> Street 9 Street Name r city
<br /> Unit 1
<br /> f A cv-���
<br /> 2
<br /> 3. — `_ —. _ ©Unit 2
<br /> 4. _ —...._ --• --- --- nit3 ��
<br /> 6.
<br /> Un It 4
<br /> 9.
<br /> 10
<br /> Specific to Range of Information Requested: From to Unit 6
<br /> _
<br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES
<br /> GROUND TANK(UST)CLEANUP SITE(LOP) MEDICAL,WASTE FACILITY )eS
<br /> CLEANUP SITE NON•LOP t� ❑SOLID WASTE FAGlL1TYIVEHICLE -a" � 3�
<br /> ( ) ❑nOt1S1w ABATEMENT [�WASTE TIRE
<br /> GROUND TANK(MDNTTORINGIREMOVAL) ❑FOOD FACH rff DAIRY 4-�,�I t
<br /> GROUND TANK 0 CHICKEN RANCHI DOG KENNEL 0 WASTEWATER TREATMENT PLANT �1J
<br /> DOUS WASTEIHAZARDOU6 MATERIALS ❑MOTELIHOTEL 0 PUMPER TRUCKIYARDICHEMIcAL T01LETs
<br /> [RtIERED PERM1ITED FACILITY ❑PDOLISPA 0 LAND USE APPLICATION SITES
<br /> ❑TATTOOBODY PIERCING ❑COMPLAIWIRESPONSE RECORDS ❑OTIM(PLEASE SPECIFY)
<br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOP,REVIEW: MONDAY-FRIDAY 8.00 AM-5:00PM (EXCLUDING HOLIDAYS)
<br /> 1. Lis uA t)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(2.08)_484.0138 Qr mail to the address indicated above Address
<br /> ranges will not be accepted-for additional assistance with file addresses,contact the EHD. Applications received atter
<br /> 3:00 prn 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. Appolntments
<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 avallable.
<br /> 4. Any file not returned In the same condition as released will be reorganized by EHD staff at the expense of thea tieant.
<br /> Future the revlews by the same applicant may require a$125 deposit rior to review, I
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<br /> R e c e�i v e d T i me A p r, 15. 2014 3: 3 5 P M No. 5798
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