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REGE <br /> VED <br /> DK <br /> I SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> FEB 0 y 2016 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East wazelfon_Avanue,-Stockton CA9.5205-6232 6 <br /> • ENVIRONMENTAL F one: (209) 468-3420 Fax: (209) 464-0138 Vdeb: www.sjgov.org/ehd <br /> PERMIT/SERVICES <br /> P'UEI_IC RECORDS RELEASE APPUC T IOM <br /> APPLICANT: C4FXWd VG( VI Dyke, BUSINESS/AGENCYN Cr,/K(,lr'�I- _ <br /> ADDRESS: �7G' (lIW `����� �/Pi TLD CITY/STATEIZIP: PCltj1C,ulol , /)Z 7ZI7L <br /> PHONE (i):C�1��- V I PHONE (2): FAX OR E-MAIL: %2 " <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 OR <br /> O�"CH�,ECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> T <br /> SIGNATURE OF APPLICANT � 'f�c l,CirL(i� . DATE <br /> Electronic Information: ❑ List❑ Map-Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street# Street Name City ,.n <br /> Lo� (�—`V ❑Unit'i <br /> P2. ❑ Unit2❑ Unit 2H� -�( ❑ Unit a <br /> ❑Unit 3 M. nit 4 <br /> 8. <br /> ITE MITIGATION <br /> 9. <br /> 1D ❑ Unit 5 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH CEPART:4ENIT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MOTELIHOTEL ❑SOLID WASTE FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑FOOD 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 TRUCKNARDICHEMICALTOILETS <br /> ❑HAZARDOUS MATERIALS ❑TATTOOIBODY PIERCING ❑LAND USE APPLICATION SITES <br /> ❑TIERED PERMITTED FACILITY ❑COMPLAINTIRESPONSE RECORDS ❑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 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.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. <br /> ***BOXED AREA-EHD USE ONLY*** <br /> n)JAG� LOPrileLA61 fjee� 4-ar Q0 Tunef R CD. <br /> 0 Records provided by Staff-PPR Complete. staff Name: <br />