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i Rug 10 2015 11:21RM Envi n Phase Consulting 213 18-6009 p.1 <br />I`V I�® EHD LOG NUMBE <br />SAN JOAQUIN COUNTY <br />AUG 10 2015 ENVIRONMENTAL HEALTH DEPARTMENT <br />168 East Hazelton Avenue, Stockton, CA 95205-6232 <br />(209) 468-3420 Fax: (209) 464-0138 Web; www.sjgov.org/ehd <br />TMRONMENTALHt�hone: <br />PERMITISERVICES PU L1C RECORDS RELEASE APPLICATION <br />p <br />� ovI t) <br />`��S" C4ADDR_SS: <br />1 <br />APPLICANT: <br />-��BUSINESS/AGENCY; <br />CITY/STAT�IP: <br />PHONE (1):7i,�i PHONE (2): FACSIMILE: <br />Please allow 10 business days from date of application submittal for the records to be available. <br />date and time to review the requested records. <br />Staff will contact yo to arrange an appointment <br />❑ CHECK BOX TO EXPEDIT, REQUEST - $130 FEE (CASH OR E K ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE <br />Electronic Information: ❑ List [I Map -Description: <br />FILE <br />ADDRESS EHD USE ONLY <br />Street Name I City <br />Street # <br />E] Unit <br />1 <br />2 <br />2. - <br />❑Unit <br />3. <br />["W5'�145 G�tl CJ Unit <br />H <br />4. <br />-E]Unt3 <br />i' <br />6. <br />7 <br />1'1] Un <br />t 4 <br />DNI <br />B. <br />SITE MITIGATI <br />9. <br />❑ Units <br />10. <br />Specific Date Range of Information <br />Requested: From to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEAN <br />P SITE (LOP) L] MEDICAL WASTE FACILITY ❑ SOLID WASTE FACILITYNEHICLE <br />OTHER CLEANUP SITE (NON LOP) <br />F] HOUSING ADATEMENT ❑ WASTE TIRE <br />❑ DAIRY <br />UNDERGROUND TANK (MONITORING <br />❑ ABOVEGROUND TANK <br />REMOVAL) ❑ FOOD FACILITY <br />❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATERTREATMENT PLANT <br />iAZARDOUSWASTE/HA7A}ZROUSM MATERIALS <br />❑MOTEOHOTEL❑PUMPERTRUCKIYARDICHEMICALTOILETS <br />[I TIERED PERWITTED FACILITY <br />❑ POOLISPA ❑LAND USE APPLICATION SITES <br />❑ COMPLAINTIRESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <br />❑ TATTOOIBODY PIERCING <br />WELL AND SEPTIC PERMIT RE <br />ORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 ANT-5:00PM (EXCLUDING HOLIDAI�S) <br />1. List up to ten addresses in <br />the space above. Select the type(s) of files from the list above by checking the appropriate <br />3e MUST be selected. Fax to (2 9) 464-0138 or mail to the address indicated above. AddreE <br />s <br />box(es). At least one file ty <br />ranges will not be accepted. <br />Applications received after 3;00 pm will be processed the next business day. <br />2. For assistance in identify! <br />g the nature and content of EHD records, please contact EHD at the number noted above. <br />3. The EHD will notify the app!cant <br />if any EKD files exist. An appointment for review will be confirmed approximately ten <br />be held for maximum of five business days for review. Appointments <br />1 <br />days after receipt of appllc <br />tion. The files will a <br />should be scheduled accordingly, <br />4. Any file not returned in the <br />samelcondition as released will be reorganized by EHD staff at the expense of the applicant <br />***BOXED AREA •EHD USE ONLY <br />­ <br />Future file reviews by the some <br />applicant may require as $130 deposit prior to review. <br />Records provided by Staff -PPR Complete. Staff Name: <br />7A it 5 <br />Received Time Aug.10. 2015 10.54AM h-9304 <br />