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LI�� EHD LOG NUMBER 1L�. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 0 C T 21 2014 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd ENVIRONMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION APPLICANT: I n qC -1 yr e- BUSINESS/AGENCY: 3\ S lcC a �GT� ADDRESS\ i(A-n (� 7\pQN'r� �� CITY/STATE/ZTP: Lo-OT PHONE(1): Z09 r Zoe--7 ZSj PHONE (2): FACSIMILE: Please allow 10 business days from date of application submittal for the records to be available. Staff will contact you to arrange/an appointment date and time to review the requested records. El CHECK BOX TO EXPEDITE REQUEST-$4YEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OF APPLICA T � �� _ DATE I o 21/ J`� Electronic Information: El Lit 71Map-Description: FILE ADDRESS EHD USE ONLY Street# Street Name City ❑ Unit 1 1. 12171-) N __TV_\kA_QT0Q Lo_Ib.1._ (JP- ��- /3 2. ❑Unit 2 3. %4. ❑Unit 3 5. LN 6. ❑Unit 4 7. 8. / ❑Unit 5 9. 10. ❑ Unit 6 Specific Date Range of Information Requested: From to ENVIRONMENTAL HEALTH DEPARTMENT FILES ❑UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYIVEHICLE ❑OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE ❑UNDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRY ❑ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT ❑HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTEL/HOTEL ❑PUMPER TRUCKIYARD/CHEMICAL TOILETS ❑TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES l ❑TATTOO/BODY PIERCING ❑COMPLAINTIRESPONSE RECORDS OTHER(PLEASE SPECIFY)-L.4- WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) 1. List up to ten addresses in the space above. Select the type(s)of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the address indicated above. Address ranges will not be accepted.Applications received after 3:00 pm will be processed the next business day. 2. For assistance in identifying the nature and content of EHD records,please contact EHD at the number noted above. 3. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten(10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a$125 deposit prior to review. ***BOXED AREA-EHD USE ONLY*** i ❑ Records provided by Staff-PPR Complete. Staff Name: EHD 48.06 w -728T'14