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D k ' AOa _- E ID LOG NUMBER <br /> SAN ,JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> f MAY O 2 2 13 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468=3420-Faz:(209)464=0138 Web: Www.$)gov.org/ehd <br /> ° ENVz4,nVX4V0NTA HEAL--CH <br /> ;ICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: G (�!2)crV KC)COSe BUSINESSIAGENCY: (A <br /> ADDRESS: _ag GN lay j�c'kS a✓� h�2r?d CITY/STATE/ZIP: C/+j/yt'H <br /> PHONE (1): % 67qa0-71 PHONE(2): q16 7/i--634J7 FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of.application submittal- Time: <br /> only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$125FEE CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE 5� <br /> Electronic Information: gList❑ Map—Description: <br /> FILE ADDRESS EHD Use ONLY <br /> Street# Street Name city <br /> ao !PC pr t <br /> t <br /> Unit 11. 0 RoA A <br /> 2. 01-A- ❑ <br /> $ rS <br /> 4. ar 1r/ - <br /> 5 <br /> _,01UnIt 3 <br /> La <br /> 6. , / 7 <br /> T C� ❑finita <br /> ❑Unit 5 <br /> 10. �tb I 29(a 0 <br /> ❑Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYJ VEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL - ❑WASTEWATER TREATME NT PLANT <br /> HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDI HEMICAL TOILETS <br /> ❑TIERED PERMITTED FACILITY' ❑POOLISPA <br /> ❑TATTOO/BODY PIERCING ❑LAND USE APPLICATION SITES <br /> ❑COMPLAINTIRESPONSEREOORDS ❑OTHER(PLEASE SPEC/ ) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDINGHOLIDAYS) <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 <br /> box(es). At least one file type MUST be selected. Fax to 209 464-0138 or mail to the address indicated above. Address <br /> ranges will not be accepted-for additional assistance with file addresses,contact the EHD. Applications recc ived after <br /> 3:00 pm will be processed the next business day. <br /> 2. 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 /> .3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be <br /> submitted when the file is available: <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$1251t deposit prior to review. ". BOXED AREA-EH USE ONLY*'* <br /> —r <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 48-96 <br /> 9/4/12 <br />