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DATE RECEIVED 0 4 O( (O N E;W nr"nii innRCR <br /> r SAN .IOAQUINCG�00 N AH, no awll Pania�a� <br /> 1. .,.. , o <br /> ENvl ;RONMENTAL HEALTH DEPARIk.LaNT <br /> 1868 E, st Hazelton Avenue, Stockton, CA 95205-6232 <br /> (�u�i ZClS <br /> Telephone: (209) f68-3420 Fax: (209)464-0138 Web: www.sjgov,org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: Aq,, U1'^y BUSINESS/AGENCY: 5�,rg��ns <br /> ADDRESS: 333 U Cu .L,rO�tpc,-l �� <br /> X5-0 CITY/STATE/ZIP: <br /> PHONE (1): `jI(v� �-Ib�� _ _ PHONE (2): FAX OR E-MAIL: 930-��6" C9ous <br /> Please allow 10 business d lys from date of application submittal for the records to be available. aJ,, <br /> Staff will contact you to ar ange an appointment date and time to review the requested records. 5i,,A+ <br /> ❑ CHECK BOX TO EXPEDITER ST 130 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT � DATE i ll).S/ 15" <br /> Electronic Information: ❑ List❑ Aap e Description: <br /> FILE AC aRESS <br /> EHD USE ONLY <br /> Street Street lame City <br /> ❑Unit 1 <br /> 2. <br /> 3. ❑Unit 2 <br /> ❑ Unit 2H <br /> 5. ( Unit3 <br /> ' 6. ElUnit 3HM <br /> 7. DUnit 4 <br /> 8. ❑SITE MITIGATION <br /> 9. <br /> ❑ Unit 5 <br /> 10. <br /> Spectflc Date Range of information Requested: Fron Iq�{� l�9 T�-�o oSs 1 �+Vfl l0 0 II.I -1J I S 11)-i' <br /> E WIRONMENTAL HEALTH DEP KTMENT FILES <br /> Y' UNDERGROUND TANK(UST)CLEANUP SITE(L )P) ❑MOTELIHOTEL ❑SOLID WASTE FACILITY/VEHIC G <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑FOOD FACILITY '1 U 5 7 11,un- (�✓� <br /> [�UNDERGROUND TANK(MONITORINGIREMOVAIt� ❑WASTE TIRE ❑DAIRY,POOL/SFA �t <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCH)DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ❑HAZARDOUS YVASTE []MEDICAL WASTE FACILITY ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑HAZARDOUS MATERIALS ❑TATTOO/BODY PIERCING ❑LAND USE APPLICATION SITES <br /> ❑TIERED PERMITTED FACILITY ❑COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMI I RECOF )S ARE AVAILABLE FOR REVIEW: MONDAY-FRID 8:00 AM-6:00PM EXCLUDING HOLIDAYS <br /> 1. List up to ten addresses in the spat -above. Select the type(s) of files fr the list above by checking the appropriate <br /> box(es). At least one file type MUS-I be selected. Fax to 209 454-09 or the <br /> to the address indicated above. Address <br /> ranges will not be accepted.Applicr :ions received after 3:00 pm w- a processed the next business day. <br /> 2. For assistance in identifying the na ure and content of EHD r ords,please contact E:HD at the number noted above. <br /> 3. The EHD will notify the applicant If a ny EHD files exist. appointment for review will be confirmed approximately ten(10) <br /> days after receipt of application. Tt 3 files will be he or a maximum of five business days for review. Appointments <br /> should be scheduled accordingly. <br /> 4. Any file not returned In the same cc tdition released will be reorganized by FHD staff at the expense of the applicant. <br /> Future file reviews by the same app !can ay require a$130 deposit prior to review. I Z�I� <br /> —BOXED AREA-EHD USE ONLY' <br /> - t <br /> -T # 3 fj 1'e- h <br /> a - rP iv1�1 U�nt 00;5 0-73 , s (�t7rrl x�o ��d m) n Al � <br /> i r✓I �i <br /> TO/ZO 3J�d �y1NElJ02iIrsN3 Sf11��i1S aO��. <br /> 50099L90cl5 T9:3T STOZ/5Z/TT <br />