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DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT � f <br /> DEC 02 2015 1868 East Hazelton Avenue, Stockton, CA 95205-623 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> EIvIVIRCN1IcaEitfT,^,LHEAl:t3-y PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: 1 SOyYC'L l A1C. BUSINESS/AGENCY: <br /> ADDRESS: ���Q � 5� r` � �. CITY/STATEIZIP: <br /> PHONE (1): PHONE (2): FAX OR E-MAIL: SQtlrce-glen?. <br /> Please allow 10 business days from date of application submittal for the records to urub <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 2 2 <br /> Electronic Information: [List ❑ Map— Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street t! Street Name City 1 <br /> EaS-� v,0- Sf <br /> , <br /> 2. o2�U 5 ",%,n ❑Unit 1 <br /> S <br /> n �,� <br /> ���� stn /` `�■l _ Sz CkA-b Vj ) ❑Unit 2 <br /> 5. '_q t� S Yl NJ nit3 <br /> 6. ag Li( S 1v ` o' <br /> Unit 3HM <br /> 7. <br /> L;Unit 4 <br /> 8. 13 SITE:MITIGATION <br /> 9. <br /> 10. ❑ Unit 5 <br /> Specific Date Range of Information Requested: From I j 70 to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ®UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MOTELIHOTEL [:]SOLID WASTE FACIUTYNHICLE , <br /> ®OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT F1 FOOD FACILITY 11�j��'j rt7T/W7, 1 3 <br /> [?C UNDERGROUND TANK(MsONITORINGIREMOVAL) ❑WASTE TIRE ❑DAIRY,POOLISPA 2 C(l \C/_1_1 ((12 7-1 S <br /> V <br /> ®ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ®HAZARDOUS WASTE C' ❑MEDICAL WASTE FACILITY ❑PUMPER TRUCK/YARDICHEMICAL TOILETS <br /> HAZARDOUS MATERIALS ❑TATTOO/BODY PIERCING ❑LAND USE APPLICATION SITES <br /> ❑TIERED PERMITTED FACILITY ❑COMPLAINT/RESPONSE 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 applicants Z7Ilu,�lilr�let�' <br /> Future file reviews by the same applicant may require a$130 deposit prior to review. i2_7_15 —1 ). <br /> -BOXED AREA-EHD USE ONLY`** u�j ( f11��� Z6ll �ypl�w.�t �{co Y� <br /> uyik Ii y <br /> 11- - • Th 1f r 5 ,v yx,1t7 t <br /> a i J fOr 3 3 10, r,r: <br /> C- OnMaleter.ftaff-Neme: -7r <br /> fly,yf 5Ic)& , * i.&bV 407 Vq b 5 it (Z u -7b r 5147ly i S /1 U i P <br /> 33i0/VIi - S2- i 15: tLg� 1 55SI'D(,) uS t �i�I' fE1r oZ Wl !�lyr+ <br />