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004/15/2014 13: 06 FAX 3106154544 a001/001I.
<br /> I� DATE 12ECEIVFp EHO LOG NUMpER
<br /> ■ Y, ^i_ic"N SAN JOAQUIN COUNTY
<br /> ®■ 1', ��=° ENVIRONMENTAL HEALTH DEPARTMENT
<br /> 1865 East Hazelton Avenue, Stockton, CA 95205-6232 t
<br /> ASR F
<br /> "gfephone: (209)468-3420 Fax: (209)464-0138 Web: WWW.sjgov.org/ehd �
<br /> x
<br /> ENVIRONMENT A HEALTH PUBLIC RECORDS RELEASE APPLICATION
<br /> APPLICANT'.,,,) BUSINESSIAGENCY: �c4.
<br /> ADDRESS: CITYISTATE71P: 1
<br /> PHONE (1): j PHONE (2): FACSIMILE: 515 7_ 5
<br /> TEN Tf WE*APPOINTMENT DATE: L Tlme: Q
<br /> (Please allow 10 business days from of application submittal-=Tonfaflve only-must be confirmed)
<br /> ❑ CHEC BOX TO EXPEDITE REQUEST"-$125 FEE(CASH OR C CK ONLY)-REQUEST PROCESSED IN 3 B SIN SS DAYS
<br /> SIGNATURE Or APPLICANT DATE 11
<br /> Electronic Infq atlon: ❑ List[] Map—Description:
<br /> FILE ADDRESS EHL)USE ONLY
<br /> Street# Street Name City Unit 1
<br /> 1, _ 17 16 N _AC*
<br /> 2. '72b (.)i — +f
<br /> A V1
<br /> Unit 2
<br /> 0 -a' t'i -a�T V, I
<br /> 6.
<br /> _ - 'U'nit 4
<br /> 7.
<br /> a' Unit 5
<br /> 10 CIA Lr
<br /> 'Units•
<br /> Specific Date Rant e f Information Requested: From to
<br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES
<br /> &NDEReROUND It (UST)CLEANUP SITE(LOP) ❑MEwcAL WASTE FACILITY Tq SOLID WASTE FACiLiTYNEHICLE
<br /> OTHER CLEANUP sn E(NON-LOP) ❑HOUSING ABATEMENT VVASTE TIRE
<br /> UNDERGROUND (MONITORMHGIREMOVAL) ❑FOOD FACILITY DAIRY
<br /> BO
<br /> AVEGROUND ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT
<br /> t?HAZARDOUs WA E OUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARD/CHF-MICAL.TOUTS
<br /> RTATToo1BGMDYPi
<br /> TiERED PERNai ACILnY ❑POOUSPA ❑LAND USE APFUCATION SITES
<br /> R ING 7COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY)
<br /> WELL AND SL I1 PERMIT RECORDS ARE AVAIL ABLE FOR REVIEW: MONDAY-FRIDAY 5:00 AM-5:o0PM(EXCLUDING HOUriAY5)
<br /> 1, List up to dre6ses In the space above. Select the type(s)of files from the list above by checking the appropriate
<br /> box(es). At Iem tone file type MUST be selected. Fax to(208)464-0138 or mail to the address indicated above. Address
<br /> ranges wlli n; t e a=epted-for additional assistance wlth file addresses,contact the EHD. Applications received after
<br /> 3:00 pm will kt processed the next business day_
<br /> 2. The EHD will nc tify the applicant if any END files exfst An appointment for review will be confirmed approximately ten(10)
<br /> days atter e t of application, The files will be held for a maximum of five business days for review. Appointments
<br /> should be sc!te duled acoordingly.
<br /> 3. A file that is Ac.1vely being worked on by EHD staff may not be immediately available for review, A new application may be
<br /> submitted w e i the file Is avallable.
<br /> 4. Any file not t irned In the same condition as released will lae reorganized by EHD staff at the exe��enClsapplicant
<br /> LLe of the a� T
<br /> Future file re 1 ws by the same applleant may require a$125 deposit prior to mVIew. ;.,BpXEMFA
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<br /> P�10 48.06 8N/'IT
<br /> Received Timel APr, 15r 2014 1 ; 16PM No, 5793
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