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1� SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> MPy O9 20 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ephone: (209)468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd <br /> �NVpEy" �11�ER <br /> PUBLIC RECORDS RELEASE APPLICATIONF1 F <br /> _ I, 31i <br /> APPLICANT: I �M 5iv►��I� BUSINESSIAGENCY: ES <br /> ADDRESS: 1&6-6-I 564 t•L7u.l, _4t_y CITY/STATE/ZIP: 5�.ro.N►cn(roA Cl ?S84f <br /> PHONE(1): 7IL(- :SSS ((GZq PHONE (2): FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-`Tenfadve only-must be confirmed) <br /> ❑CHECK BOX-TO EXPEDITE REQUES EE(C R CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name / city ❑ Unit 1 <br /> 1. 143 11 - `1 e ��olF <br /> 2. 1KSc9s �� I !�'. r�G� �� Lj�f'­:�G ®,11nit2 . <br /> cro�21 <br /> 4. Znit3 �C( <br /> 5. f <br /> 6. <br /> Unit4 <br /> 7. <br /> 8. <br /> nit 5 <br /> 9. <br /> Sh? /` D Unit6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> OUNDERGROUND TANK(UST)CLEANUP SITE(LOP) [IMEDICAL WASTE FACILITY [SOLID WASTE <br /> UFACILITYIVEHICLE �b <br /> OTHER CLEANUP SITE(NON-LOP) ER HOUSING ABATEMENT WASTE TIRE <br /> [UNDERGROUND TANK(MONITORING/REMOVAL) ❑FOOD FACILITY ❑DAIRY :- <br /> ABOVEGROUND TANK 0 CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTE/HAZARDOUS MATERIALS ❑MOTEL/HOTEL ❑PUMPER TRUCK[YARD/CHEMICAL TOILETS <br /> V�TIERED PERMITTED FACILITY ❑POOL/SPA ❑LAND USEAPPLICATION SITES <br /> ❑TATTOO/BODY PIERCING [COMPLAINT/RESPONSE RECORDS ]"OTHER(PLEASE SPECIFY) 'Wk'L F mal s <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-for additional assistance with file addresses,contact the EHD. Applications received after <br /> 3:00 pm will be processed.the next business day. <br /> 2. 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 /> 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be <br /> submitted when the file is available. <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$125 deposit prior to review. ***BOXED AREA-EHD USE ONLY** <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 4B-06 <br /> 914112 <br />