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��EGWVED *SAN JOAQUIN COUNTY <br />FEB 1 1 2015 ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Ei VIRONf EN-"AL!-IETI_e phone: (209/)468-3420 Fax: (209) 464-0138 Web: www.ssjjgov.org/ehd <br />rJCDAA9Th°�� Li+L1k;A I1 <br />UN <br />BUSINESS/AGENCY& � [ <br />CITY/STATE/ZIP: - r <br />FACSIMIL ` ; 2 -7 <br />APPLICANT: <br />PHONE (1): <br />PHONE (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 CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT <br />Electronic Information: ❑ List ❑ Map— Description: <br />FILE ADDRESS EHD USE ONLY <br />Street # Street Name <br />City ❑ Unit 1 <br />❑ Unit 2 <br />a <br />3. <br />v /f Unit 3 <br />4. <br />unit 4 <br />6. <br />7. <br />❑ Unit 5 <br />8. <br />❑ Unit 6 <br />Figo. <br />1 <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 FACILITYNEHICEE r <br />❑ OTHER CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT F1WASTE TIRE � U5 -7- / , <br />UNDERGROUND TANK (MONITORING/REMOVA ❑ FOOD FACILITY ❑ DAIRY JC4 j <br />❑ ABOVEGROUND TANK ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER TREATMENTPLANT' <br />❑ HAZARDOUS WASTEMAZARDOUS MATERIALS ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEMICAL TOILETS <br />❑ TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br />❑ TATTOOIBODY PIERCING ❑ 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 />Fntitrp £Ip rpvipws by the same aonlicant may require a $130 deposit prior to review. ***BOXED AREA -EHD USE ONLY*** <br />r <br />'1 [3 Records provided by Staff -PPR Complete. Staff Name: <br />EHD 48-06 <br />