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07/29/2015 1 : 21 : 11 PM -04.r ?AXCOM ANYWHERE PAGE 4 OF 4 <br /> RSGc EIVED FILE COI'IYEHD LOG NUMBER <br /> SAN JOAQUIN COUNTYN. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> JUL 2q ZOtS �- <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> R EUTAUH4Whone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/eh <br /> PERMfffSERVM PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: ter- a, >>•. BUSINESS/AGENCY: P/1 <br /> ADDRESS: ?j �, }3�V �j" � CITY/STATE/ZIP: a ,; <br /> PHONE (1): qJ1, ��7`� `' PHONE(2): �16 �� -��7'� FACSIMILE: <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑CHECK BOX TO EXPEDITE REQUE T-$130 F E(CASH OR CHECK ONLY) -REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE i ?� <br /> Electronic Information: ❑ List Map-Description: <br /> FILE ADDRESS <br /> Street# Street NameI City EHD USE ONLY <br /> _............. ........................ <br /> �. <br /> W53 15 it I mora•-Ao 5-� <br /> 2. aK�a� �� (. c2 T), il'�trl U ❑unit 1 <br /> 3. Z'U <br /> -....._....................................................................................... <br /> nit 2 <br /> 4. <br /> ❑Unit 2H <br /> 5. i .. f <br /> ......................_. <br /> 8' 5 Unit 3 <br /> T .El'l nit 4 <br /> ............. <br /> 8. ®SITE MITIGATION <br /> ....................................... <br /> 9. <br /> o. 3 <br /> []unit s <br /> Specific Date Range of Information Requested. From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 9UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY NSOLID WASTE FACILITWVEHICLE,�10 SCO <br /> OTHER CLEANUP SITE(NON-LOP) I ElHOUSING ABATEMENT WASTE TIRE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑Fool)FACILITY ❑DAIRY <br /> ABOVEGROUND TANK ❑CHICKEN RANCHI DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WAST EIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICALTOILETS <br /> TIERED PERMITTED FACILITY ❑POOLISPA LAND USE APPLICATION SITES <br /> TATTOOIBODY PIERCING �COMPLAINTIRESPONSE RECORDS OTHER(PLEASE SPECIFY)J1,` L ° `� <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.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. f <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. "*BOXED AREA-EHD USE ONLY' <br /> ❑ Records provided by Staff-PPR Complete.Staff Name: <br /> Received Time=Jul, 29. =2015=10 : 20AM--No, 9221 <br />