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DATE RECEIVED <br /> SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> ��� ENVIRONMENTAL HEALTH DEPARTMENT <br /> SEP 03 20151868 East Hazelton Avenue, Stockton, CA 95205-6232 G C O fes` <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sigov.org/ehd <br /> EWRONMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: �I 1 j �i+) "7 BUSINESS/AGENCY: <br /> ADDRESS: It(lSJ (/yf (zp <br /> 1� ( Id' ado CITY/STgTEIZIP: GKI C �Y/ CI <br /> PHONE(1): " �D �� � y <br /> Ineft`E" MI6 6�x is— <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- 0 E (CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT____ ® DATE <br /> II Electronic Information: ❑List❑ Map-Description: <br /> FILE ADDRESS <br /> Street# Street Name Cit, EHD USE ONLY <br /> z <br /> 3 ❑Unit 1 <br /> 4. ,^ ❑Unit <br /> 5. uJ_ LI Unit 2H <br /> Ogl-� n <br /> 1 6. I� <br /> 7. Unit 3 <br /> 8 fz Unit 4 <br /> 9. ❑SITE MITIGATION <br /> 1 D. <br /> Specific Date Range of Information Requested: From to ❑unit 5 <br /> ar7 ENVIRONMENTAL HEALTHIDEPAP.TMENT FILES <br /> L�1 UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYNEHICLE <br /> Ll OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT 171 WASTE TIRE <br /> '®UNDERGROUND TANK(MONITORING/REMOVAL) (-]FOOD FACILITY ❑DAIRY <br /> ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL <br /> ❑HAZARDOUS WASTEMAZAEl WASTEWATER TREATMENT PLANT <br /> RDOUS MATERIALS <br /> El ❑PUMPER TRUCKIYAROICHEMICALTOILETS <br /> ❑TIERED PERMITTED FACILITY ❑P60LISPA <br /> ❑TATTOO/BODY PIERCING ❑LAND USE APPLICATION SITES <br /> ❑COMPLAINT/RESPONSE RECORDS El OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List un 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 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 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. ***BOXED AREA-EHD USE ONLY"** <br /> /n�`,JcJI LDP Fite a ! 2ef�s dot KT l Fwdti .� SL- <br /> to <br /> vw to <br /> d <br /> ❑ Records provided by Staff-PPR Complete.Staff Name: <br /> EUD 4e-o6 <br /> nuts <br />