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EHD LOG NUMBER DATe � �^v' ,rs t SAN JOAQUIN COUNTY ,. NOV 0 ] 2vt'=i ENVIRONMENTAL HEALTH DEPARTMENT V rl 1868 East Hazelton Avenue, Stockton, CA 95205-6232 V V ENVIROWENTALTiglppl�one: (209) 468-3420 Fax: (209) 464-0136 Web: www.sjgov.org/eh PERNHT/SERVIrr_S PUBLIC RECORDS RELEASE APPLICATION _ I APPLICANT4)n BUSINESSIAGENCY: �EOQL- 0(, �K� I2 'to(I ADDRESS: r Fqr S ►— ( _1'1(AA�4ruk, SUi }a- TYISTATE/21P:Sh(>�-ir6r)�� PHONE (1):&00°) a - 3( S3 PHONE (2). "A W FACSIMILE: Please allow 10 business days from date of application submittal for the records to be available. Staff will contact you to arrange an appointment date and time to review the requested records. ❑ CHECK BOX TO EXPEDITE REQUEST-$130 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OF APPLICANT ��y, �rctnc�� DATE Electronic Information: [-] List❑ Map-Description: FILE ADDRESS EHD USE ONLY Street k StreetNamo City —__ umiI IIj15 2. , IQ'GX -Y Y Gi+Q�r ao gd JTO G n —LIt I ❑_unit 2 3. a. J.a. h � crr, rea 1All? oos_h n ❑— _ .,__,.._ ..._.. .._._ Unit 3 5, Cao P J 2lfv)11_ SITE MITIGATION s. a��tR _ ver ern .—... ❑Unit 4 7. 8. SQ IlerisQ SQ K��_I �--�� ❑Unit s 9. 10. 1 i7nRix Specific Date Range of Information Requested: From QI t10 I to ) 1171 ENVIRONMENTAL HEALTH DEPARTMENT FILES ❑UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYNEHICLE ❑OTHER CLEANUP SITE(NON-LOP) [],HOUSING ABATEMENT ❑WASTE TIRE ❑UNDERGROUND TANK(MONITORING/REMOVAL) �FOOD FACILITY ❑DAIRY ❑A13OVEGROUND TANK •❑ IICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT ❑HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELMOTEL ❑PUMPERTRUCKIYARDICHEMICAL TOILETS ❑TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES ❑TATTOoIB00Y PIERCING ❑COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) 1. List up to ten addresses In the space above. Select the type(s)of files from the list above by checking the appropriate box(es). At least one file Type MUST be selected. Fax to(20!]H 464-0138 or mail to the address indicated above. Address ranges will not be accepted.Applications received after 3:00 pm will be processed the next business day. 2. For assistance in identifying the nature and content of EHD records, please contact EHD at the number noted above. 3. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten(10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a$125 deposit prior to review. '"BOXED AREA-EHD USE ONLY", 1 ❑ Records provided by Staff-PPR Complete:staff Name: EHe 4M6 5nin5