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V3 <br /> DATE RECEIVED SAN JOAQUIN BOUNTY EHD LOG NUMBER <br /> ENVIRONMENTAL HEALTH DEPARTMENT �'e� I <br /> ECEIV D- -- --1868-East Hazelton-Avenue,—Stockton; CA95205=6232 -- <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> IAN I`( 2656 PUBLIC RECORDS RELEASE APPLICATION <br /> ENVIRONMENTA �y <br /> 4ReRMIi7 OL-e-1 tJr� l BUSINESS/AGENCY:—� <br /> ADDRESS:,al W. L1 CITY/STATE/ZIP: I tr6 C'�.( , Cn <br /> PHONE ('I CAk0-:A5 ,4NPHONE (2): FAX OR E-MAIL: <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-$130 FEE(CASH 0 t K ONLY)-REQUEST PROCESSED IN 3 B SINE SDAYS <br /> SIGNATURE OF APPLICANT S \C( -C L 1 tL I-\, DATE I S A <br /> Electronic Information: ❑ List ❑ 10ap—Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street# Street Name City " <br /> 2. E] Unit 1 <br /> 3. ❑Unit 2 <br /> 4. ❑ Unlit 2H bt';Z^ <br /> 5• ILI'tJnin it <br /> E1,15nit 3HM <br /> 7. &Knit 4 <br /> 8• SITE MITIGATION <br /> S. <br /> ❑ Unit 5 <br /> 10. <br /> Specific Date Range of Information Requested: From to <br /> ......������yyyyyy ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> &UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MOTELIHOTEL SOLID WASTE FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT OOD FACILITY <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑WASTE TIRE ❑DAIRY,POOLISPA <br /> ABOVEGROUND TANK ❑CHICKEN RANCHI DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTE ❑MEDICAL WASTE FACILITY ❑PUMPER TRUCKIYARDICHEMICAL TOILETS f <br /> HAZARDOUS MATERIALS ❑TATTOOIBODY PIERCING 2 W <br /> LAND USE APPLICATION SITE'S,p},i:W" <br /> S' n <br /> ,®TIERED PERMITTED FACILITY COMPLAINTIRESPONSE RECORDS OTHER(PLEASE SPECIFY) t,�11 l <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(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'1S CIIN <br /> box(es). At least one file type MUST be selected. Fax to(208)464-0138 or mail to the address indicated above. Addreiiisss``` <br /> ranges will not be accepted.Applications received after 3:00 pm will be processed the next business day. (`r1� f �( <br /> 2. For ass late noa 1n identifying the nature and content of EHD records,please conm <br /> tact EHD at the nuber noted above. C( `► <br /> 3. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10�7.l1" <br /> days after receipt of application. The files will be held for a maximum of five business days for review. Appointments �0- /� �. <br /> should be scheduled accordingly. - 1-0 .,I , el <br /> 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant.'SC , 1 <br /> Future file reviews by the same applicant may require a$130 deposit prior to review. <br /> ***BOXED AREA-EHD USE ONLY*** <br /> [)(04jel LOP CilleS ,l 00 Lut <br /> 0 Records provided by Staff-PPR Complete. staff Name: <br />