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DATE RECEIVED EHD LOG NUMBER <br /> SAN �90Ai�UIN COUNTY <br /> R EIVED ENVIRONMENTAL HEALTH DEPARTMENT ? [-- , g), <br /> 1868 East Hazelton Avenue,.Stockton, CA 95205-6232 <br /> SEP 0 8 2015Telephone: (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.brg/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> PER�R' BUS1�lESS/AGENCY: <br /> APPLIC 'u i� ✓'�'1 ?�i'h1L: <br /> ADDRESS: CITY/STATE/ZIP: <br /> PHONE (1): kf zu PHONE 2 -r �'J�ACSIMILE:It�i )(41. <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 DATE ��0 �/C�; <br /> Electronic Information: ❑ List ❑ Map—Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street# Street Name City <br /> 1. %�o S ' �i'I f��i AVQi t <br /> 2. 1�7v� � f /if'If� 1LUo`� R"A-co 1 ❑Unit 1 <br /> 3. I—j-41 uU �j i^✓i!IvIP/(/ �W'� i1cZ^r �./ lye -CO L —CJt ®Unit 2 <br /> 4. o��1�! Ut.f �"t�i I�✓�G��1CG;i l✓ kNn _L� Unit 2H <br /> 5. _�h% 'l U„t c� ��'l (1/1 c�✓tI Nor <br /> 6. 1/v` L rl,4 I`� v MGE t n '611 PNvu�eal��I�Q (�C� Unit 3 <br /> 7. p u it 4 <br /> 8. 1'107 SITE MITIGATION <br /> 9. <br /> 10. ❑ Unit 5 <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 FACILITYNEHICLE <br /> gOTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> []ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ®HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKNARDICHEMICALTOILETS <br /> TIERED PERMITTED FACILITY ❑POOLISPA [9 LAND USE APPLICATION SITES <br /> ❑TATTOOIBODY PIERCING [COMPLAINT/RESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(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. ***BOXED AREA-EHD USE ONLY*** <br /> ❑ Records provided by Staff-PPR Cori-,plete. Staff Name: <br /> 7ni1s <br /> EHD 48-06 <br />