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06/14/2012 14:15 FAX 559 442 5081 KLEINFELDER C1001/001 <br />L" <br />EHD LOG NUMBER <br />DATE RECEIVED SAN JOAQUIN COUNTY <br />mw ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 (�/ehd <br />4,I c i�_, Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sl9 <br />/�`o efPUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: �' /L �- l '" n� �� BUSINESS/AGENCY: !� /4l -tCc lc>*e K. <br />-t A r,� CITYISTATEIZIP: 9 701 <br />ADDRESS: ! �r' o S <br />�-- 57%- l�y5g PHONE (2): 12-S �- �4� L FACSIMILE: <br />PHONE (1): j Time: <br />TENTATIVE* APPOINTMENT DATE: <br />(Please allow 10 business days from data of application submittal -'Tentative only - must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST - $125 FEE (CASH OR CHECKONLY) - REQUEST PROCE55 <br />n eTDt3 �! BUSINESS DAYS <br />SIGNATURE OF APPLICANT <br />Electronic Information: <br />Street # <br />1. Z.- <br />2, i019n <br />❑ List ❑ Map — Description: <br />.Mt <br />street Name <br />Q Ch <br />City <br />�t,ir�b r-•� <br />ck +t'_' <br />afia� <br />w <br />IA <br />Specific Date -Range of Information Requested. ro <br />ENVIRONMENTAL HEALTH D PARTMENT FILES ` (SIJ <br />ROUSING ABATEMENT ❑ SOLID WASTE FACILITYNEHICLE� �t!� <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ ❑ WASTE TIRE <br />OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY <br />-SER <br />TANK (MONITORINGIREMOVAL)�, ❑ DOG KENNEL DAIRY i <br />CHICKEN RANCH ❑ WASTEWATER TREATMENT PLAN <br />5�01AZARDOUS WASTE GENERATOR ® CHICKEI RAN ❑ PUMPER TRUCKIYARDICHEMICAL TOILETS <br />❑ TIERED PERMITTED FACILITY ❑ P 6TELIH ❑ LAND USE APPLICATION SITES <br />❑ TATTOOIBODY PIERCING ❑ COMPLAINT RECORDS ❑ OTHER (PLEASE SPECIFY) <br />❑ MEDICAL WASTE FACILITY <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 fele type MUST be selected. Fax to 209 464-0138 or mail to the address indicated aboveived afters <br />ranges will not be accepted - for additional assistance with file addresses, contact the EHD. Appl <br />3:00 pm will be processed the next business day. ten <br />2. The EHD will notify theapplicantIf any EHD files exist An appointment for review will befor <br />it review. <br />approximately. Appointmnts (10) <br />days after receipt of application. The files will be held for a maximum of five business days for review. App <br />should be scheduled accordingly. <br />not be immediately available for review. Anew application maybe <br />3. A file that is actively being worked on by EHD staff may <br />submitted when the file is available. <br />• 4. Any file not returned in the same condition as released will be reorganised by EHD staff at the expense of the applicant. <br />Future fele reviews by the same applicant may require a $125 deposit prior to review. <br />1. *"n UI-C'Mo4i V.R� <br />r * s <br />