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r <br /> EHO LOG NUMBER <br /> )ATE RECEIVED SAN 1 SAN JOAQUIN COUNTY <br /> REP,�`1�� 1 V iI� �1 ENVIRONMENTAL HEALTH DEPARTMENT <br /> \1� 304 East Weber Avenue,3'Floor, Stockton,CA 95202-2708 <br /> j(o, 3 <br /> 3 2 8 ?0.05' Telephone:(209)468-3420 Fax:(209)464-0138 Web:ww%v.sjgov.org/ehd <br /> ENV1 0�jNiENT 11EALTN PUBLIC RECORDS RELEASE APPLICATION.- <br /> APPLICANT: ,��; Lc„� � BUSINESSIAGENCY• <br /> AP <br /> ADDRESS <br /> PHONE(i): ',3�-1 to PHONE(2): 9 t�a Z22 5 FACSIMILE: <br /> TENTATIVE'APPOINTMENT DATE: 3 , <j'-_ Time: <br /> (Please allow 10 business days from date of application submittal-"Tentative only-must be canflrmed) <br /> ❑ CHECK BOX To EXPEDITE REQUEST.$93100 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT �o'k'__ <br /> V .1011 <br /> DATE ZjZ t '' <br /> 7 <br /> UNIT DISTRIBLYf10N I Unit 1 ❑ Unit 2 ❑UnIt3 Unit 4_ ❑Unit 5 ❑ Unit 6 17 Other(el"oniellistslmaps) <br /> FILE ADDRESS EHD USE ONLY f <br /> Street fF <br /> street Name a .y City <br /> 1. 1 75 14[1s L 1 r CJ i c 'J �.:•- f l7 �d S�O�C 'c-4-� <br /> 2. <br /> 3. L l 3 r <br /> fr 1 i:'i <br /> ZZ <br /> 7. � <br /> 10. 1 D Q�rt <br /> Specific Date Range of Information Requested:From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> y� lvhrpERGRDUND TANK(UST]CLEANUP SITE(LOP) C3HouSIWABATEMENT CI SOLID WASTE FAcILITYIVEHICLE <br /> }aL �Ftp FACILITY 0 WASTE TIRE <br /> 0 OTHER CLEANUP SITE(NON-LOP) 0 DOC FACILINEL O DAIRY <br /> 0 LINOERGROUNDTANK(MDNITORSNGIREMONAL] ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> 0 HA7.ARDOUS WASTE GENERATOR ❑PumpERTRUCKNARDICHEN TOILETS <br /> ❑TIERED PERMITTED FACILITY Ci MOTELIHOTEL <br /> 0 POOLISPA 13 LAND USE APPLICATION SI <br /> t7 TAT7001BODY PIERCING TES <br /> ,I <br /> 13 MEDICAL WASTE FAmry CI OTHER(PLEASE SPEC <br /> WELL AND SEPTIC PERMiT RECORDS ARE AVAILABLE FOR REVIEW- MONDAY-FfaOAY 8:00 AMS.00PM . EXCLUDING HOLIDAYS. <br /> 1. List up to ten addresses in the space above. Select the type(sl of files from the list above by checking the i <br /> appropriate box(es). At least one file type MUST be selected. Fax to 209I 464-0138 or mail to the address <br /> indicated above. Address ranges will not be accepted—for additional assistance with file addresses,contact <br /> the EHD.Applications received after 3:00 pm will be processed the neat business day.. <br /> 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> approximately ten (10)days after receipt of application. The files will be held for a maximum of five business <br /> days for review. Appointments 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 <br /> application may be submitted when the file is available. <br /> 4. Any file not returned in the same condition as released will be re a g93 DO deposit pEHD rior at the <br /> expense of the <br /> applicant- Future Tile reviews by the same applicant may req <br /> EHD 4a.DZ4X9 <br /> 1114f05 . <br /> Z'd 8996'199 60Z uaIIV uen m9J(1 d99:V0 g0 9Z qej <br />