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Aug 10 2015 11 : 21AM Envi n Phase Consulting 213 18-6009 p. 1 <br /> ■ <br /> ■ <br /> ■ <br /> I` I�® EHD LOG NUMBE <br /> V <br /> ■ SAN JOAQUIN COUNTY <br /> AUG 10 2015 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 168 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ENVIRONMENTALHt�hone: (209) 468-3420 Fax: (209) 464-0138 Web; www.Sjgov.org/ehd <br /> PERMITISERVICES PU L1C RECORDS RELEASE APPLICATION p <br /> � BUSINESS/AGENCY; 0181 `�� 11C. <br /> APPLICANT: �f <br /> rel -�.�j� CITY/STATiJZIP: <br /> ADDRESS. a <br /> PHONE(1): 7)11 2, PHONE (2): FACSIMILE: <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact yo to arrange an appointment date and time to review the requested records. <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 ADDRESS EHD USE ONLY <br /> Street# Street Name I City <br /> 2. - E] Unit 1 <br /> 3. ❑ unit 2 <br /> 4. G�tl• (.� <br /> 5. <br /> d� �y � Unt3 <br /> 6. !" <br /> 7 -❑Unt4 <br /> B. SITE MITIGATI DNI <br /> 9. <br /> 10. El Units <br /> Specific Date Range of Information Requested: From 1O <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEAN P SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING A9ATEMENT ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORING REMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATERTREATMEN7 PLANT <br /> AZARDOUSWASTE/HA7A}ZROUSM MATERIALS ❑MOTEOHOTEL ❑PUMPERTRUCKIYARDICHEMICALTOILETS <br /> li� ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> [I TIERED PERWITTED FACILITY <br /> ❑TATTOOIBODY PIERCING ❑COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RE ORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 ANT-5:OOPM(EXCLUDING HOLIDAILS) <br /> 1. List up to ten addresses inthe space above. Select the type(s)of files from the list above by checking the appropriate <br /> box(es). At least one file ty a 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 identify! 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 if any EKD files exist. An appointment for review will be confirmed approximately ten 10) <br /> days after receipt of appllc tion. 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 samelcondition as released will be reorganized by EHD staff at the expense of the applicant <br /> - <br /> Future file reviews by the s me applicant may require as$130 deposit prior to review. ***BOXED AREA • EHD USE ONLY <br /> ��1�} 3 A 51 0 6 T41 sfl <br /> Records provided by Staff-PPR Complete. Staff Name: <br /> Ails <br /> Received�Tirme Aug. 10. 201 10. 54AM No. 9304 <br />