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i Rug 10 2015 11:21RP1 EnviAftn Phase Consulting 213 AdhinB-0009 P.1 <br />I'VED ■ <br />EHD LOG NUMBS <br />SAN JOAQUIN COUNTY <br />AUG 10 2015 ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />R®NMENTALH hone: (209) 468 w <br />3420 Fax: (209) 464-0138 Web, ww.sj9ov.org/ehd <br />EW <br />PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: 9�i �it1 !! BUSINESSIAGENCY: tayl `) t itllJt. <br />�Q CITY/STATIIP: <br />ADDRESS: _ <br />PHONE (1): PHONE (2): FACSIMILE: <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 BOXTO EXPEDITE REQUEST - $190 FEE: <br />SIGNATURE OF APPLICANT <br />Electronic Information: <br />Street # <br />T. 0 � � <br />2. - <br />3. <br />4.. <br />5. <br />6. . <br />7'. <br />❑ List ❑ Map - Description: <br />ONLY) - REQUEST PROCESSED IN 3 BUSINESS <br />�► DATE_ <br />FILE ADDRESS <br />Street Name City <br />8. <br />9. <br />10. "ELL <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />EHD USE ONLY <br />ONDERGROUND TANK (UST, CLEANUP SITE (LOP) E] MEDICAL WASTE FACILITY [-]SOLID WASTE FACILITYiVEHICLE <br />THER CLEANUP SITE (NON -LOP) ❑ HOUsiNG ABATEMENT [:IWASTETIRE <br />?&ONDERGROUND TANK (MONITORINGIREMOVAL) ❑ FOOD FACILITY- ❑ DAIRY <br />ABOVEGROUND TANK ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER TREATMENT PLANT <br />91WARDOUSWASTEIHAZARDOUS MATERIALS ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEMICAL` <br />TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br />P [] COMPLAWTIRESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <br />1ATT00%B001 IERCING <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY B:00 AM-5:OOPM (EXCLUDING HOLIDAYS) <br />1. List up to ten addresses in the space above. Select the types) of files from the list above by checking the appropriate <br />box(es). At least one file type MUST be selected. t=ax 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 />..__.-. _ momma anniir•ant ma.. rPnuire a 5130 deposit prior to review. —BOXED AREA -,EHD USE ONL <br />❑ Records provided by Staff -PPR Complete. staff Name: <br />nns <br />Received Time Aug.10. 2015 10:54AM No.9304 <br />