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DATE RECEIVED EHO LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazolton Avenue.Stockton,CA 95205-6232 <br /> Telephone:(209)4683420 Fax:(209)464-0138 Web:www.sjgov.org/ohd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT; BUSINESS/AGENCY: <br /> ADDRESS: I — <br /> PHONE(1): �Qlr'__ _ --- mak- 0 CITYISTATE/ZIP: 0C. <br /> SG __-Y1_Y"�b S PHONE(2): FAX OR E-MAIL: fJR <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 REQUEST-V30 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT_ %J_ �' DATE J�?kZl(e <br /> 1. List up to ten addresses In the space below. Select the type(s)of files from the list below by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to 13091464.0138 or mall 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 flies 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 /> Futuro filo reviews by the same applicant may require a$130 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 6:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ Llst❑ Map—Description: <br /> Specific Date Range of Information Requested: From to <br /> -ENVIRONME <br /> NTA <br /> L <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES EHD USE ONLY <br /> ❑UNnr RGRLVNO TANK(UST) Street a Street Name City <br /> nU AN SITE(LOP) <br /> ❑ <br /> (�c � - ` ��,Pip•r ❑coNewER Onn R CI fANDP SITE(Nor-LOP) y3 �TLN'NJ�S�_ S � -LD <br /> ❑HA;gItDCUS WASTE <br /> TICRLU PERMITTED FACILITY 2 <br /> ❑DMRY <br /> ❑MOvLGRODNO TANK <br /> ❑UST (MONITORING I REMOVAL 13 $ <br /> ❑HAZARLWUS MAIERIALS 1 <br /> SPIWRELEASE RESPONSE V •vV�1.�yJ/ <br /> E]SOLID WASTE FACNTY/VEHICLE A (L_ ❑WATER CNAUry <br /> ❑FOOD FACILITY 1 jig <br /> i 76'I(v <br /> ❑PCXX/SPA <br /> ❑DAtNY 5 0 SITE MR.R. <br /> DAIR <br /> ❑LAND USE APRICATI.SITES <br /> ❑SEPTIC PUMPER TRUCK/ e Q HOUSING <br /> YARD/CHEMICAL TOILETS <br /> ❑WASTEWATER TREATMENT PLANT <br /> ❑HOUSN13 CUPAG ABATEMENT T <br /> ❑MOTEUHOTEL <br /> CHICKEN RANCH!DDG KENNEL dCUPA-FV AT <br /> Mmlcu WASTE FACILITY <br /> ❑TATTWIaOOY PIERCING <br /> ❑WASTE TIRE e ❑SOLN WASTE <br /> COMPIANT <br /> Eg'OTHCR(PLEASE SPECIFY): <br /> 10 I]ACOWxnNO <br /> 7L.5W1cly <br /> —BOXED AREA•EHD USE ONLY— <br /> p Records provided by Staff-PPR Complete.Staff Nam <br /> scanned by CamScanner <br />