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TE;IRECEIVE EHD LOG NUMBER <br /> �° ED SAN ,IOAQUIN COUNTY f�°"'"" � <br /> ENVIRONMENTAL HEALTH DEPARTi0#N17 <br /> DEC 0 2 2015 1868 East Hazelton Avenue, Stockton, CA 95265-623,1 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> ENVIRONrdIENTALHEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> �itltl S�rTI of ,((��C <br /> SOv�rQ_ � I ��1G -BUSINESS/AGENCY: <br /> APPLICANT: _ 'l rI <br /> ADDRESS: '5429 f� {t tlY� /�r^`� _ CITYISTATE/ZIP:_P o Q oALf rt((/ (tA q K;z3 <br /> PHONE (1): PHONE (2): cj7s=a8S-93y3 FAXORE-MAIL: (jW `IIl2seu rw. <br /> Please allow 10 business days from date of application submittal for the records to be avails le. r e d <br /> Staff will contact you to arrange an appointment date and time to review the requested records, <br /> 9-(CHECK BOX TO EXPEDITE REQUEST-$130 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNTURE OF APPLICANT DATE Z 2 <br /> Electronic Information: XList❑ Map—Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street# Street Name City <br /> 1' <br /> 9,'71� E.asi- t')'11hoY v-0 1hri ❑unit 1 <br /> 2. ;ZgOSS .rAIl ir. - <br /> 8. ❑Unit 2 aj4 <br /> 4. 3(O ^ . 1 ❑Unit 2H (_ tJV.A`� <br /> 5. raq tk E P S n BUnit3 iJ <br /> B. allyl s <br /> Unit 3HM <br /> 7. UAfnit 4 <br /> B. I l2 SITE MITIGATION <br /> 9. <br /> ❑Unit 5 <br /> 10. <br /> Specific Date Range of Information Requested: From 1170 to 20I9— <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ®UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MOTELIHOTEL ❑SOLID WASTE FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑FOOD FACILITY <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑WASTE TIRE ❑DAIRY,POOLISPA <br /> ®ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ®HAZARDOUS WASTE ❑MEDICAL WASTE FACILITY ❑PUMPER TRUCK/YARDICHEMICAL TOILETS <br /> 0 HAZARDOUS MATERIALS ❑TATTOO/BODY PIERCING ❑LAND USE APPLICATION SITES <br /> ❑TIERED PERMITTED FACILITY ❑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(2091464-0138 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. <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. <br /> "'BOXED AREA-EHD USE ONLY*" <br /> O Records provided by Staff-PPR Complete. Staff Name: <br />