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BATE RECEIVED 1rl-lb LOG NUMBER <br /> r%Z SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> FEB 2i�13 E 868 Fast Hazelton Avenue, Stockton, C 2105'023 f <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 W b:�wwur.sjg �: c/e <br /> NVs 0-,4zC TS' <br /> !jERMV>S�� PUBLIC RECORDS RELEASE APPLICATION <br /> ER��ICIM� <br /> APPL[CANT:IN9bIl,( UA ?P-DPEI�TI�S , U-.C_ BUSINESSIAGENCY: <br /> ADDRESS: '61bwo S . _8'Nf i, PC a_ � CITYISTATEIZIP:'~C'�A �( C {� °f S 3D <br /> PHONE (1): WC1 . t4l[pLf- 1.o-7dO PHONE (2): FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$1 5 FEE(CASH CHE OV)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE -2— <br /> Electronic <br /> Electronic Information: ❑ List❑ Map- Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑ Unit 1 <br /> 7-0' v ,rte L2o -T-12A-Cy <br /> 2. Zi /29 T/L A-G ❑ Unit 2 <br /> 3. <br /> 4. <br /> ❑ Unit 3 <br /> 5. <br /> 6. <br /> ❑ unit a <br /> 7. <br /> 8. <br /> ❑ Unit 5 <br /> 9. <br /> 10. <br /> ❑ unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYIVEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ❑HAZARDOUS WASTEIHAZARDOUSMATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCK/YARDICHEMICALTOILETS <br /> ❑TIERED PERMITTED FACILITY ❑POOLISPA LAND USE APPLICATION SITES <br /> ❑TATTOoIBODY PIERCING ❑COMPLAINTIRESPONSE 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-for additional assistance with file addresses, contact the END. 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 be held 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_ —BOXED AREA-EHD USE ONLY*** <br /> 7 ( Y('� lvr <br /> Records provided by Staff-PPR Complete. Staff Name: <br /> HD 48-06 gram <br />