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RECENED <br />DAT '- EHD LOG NUMBER <br />�A�E I 1IVrE2 2016 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />l ENFAtROMAMITALI H F -H 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />E6�I d�SCiI Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: WWW.sjgov.org/ehd L f <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: {�.< 1',� } �': (a. i i' BUSINESS/AGENCY: <br />ADDRESS: tii'`iC I411j •`,f 11.�L: CITYISTATEIZIP: r, <br />PHONE (1): -I_.,-7.x11_ i -j L..r- PHONE (2): FAX ORE -MAIL: IsI\'.,a.'',, <br />Please allow 10 business days from date of application submittal for the records to be available. <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 BUtSINESS DAYS <br />SIGNATURE OF APPLICANT ''\,? ; Ir 9 : :.r.:i DATE `D11 f 11,�s <br />1. List up to ten addresses in the space below. Select tho types) of files .from the list below 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 reviews will be confirmed approximately ten (10) <br />days after receipt of application. The files will be held for 3 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 applicant. <br />Future file reviews by the same applicant may require a $130 deposit prior to review. <br />WELL AND SEPTIC PERIYIi'I RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY ii:00 AM-5:UUPNI (EXCLUDING HOLIDAYS) <br />Electronic Information: ❑ List ❑ Map — Description: <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />LES <br />FILE ADDRESS <br />EH® USE ONLY <br />F,_'j UNDERGROUND TANK (UST) <br />Street # <br />Street Name <br />City <br />, <br />I <br />` i I? <br />I- <br />Aj{ ❑ CONSULTER <br />Zvi ►/ <br />CLEANUP SITE (LOP) <br />j OTHER CLEANUP SITE (NON LOP) <br />HAZARDOUS WASTE <br />TIERED PERMITTED FACILITY <br />ABOVEGROUND TANK <br />y J `I <br />Iv U�bt <br />DAIRY <br />1 <br />❑ P"vs <br />' aUST (MONITORING! REMOVAL) <br />HAZARDOUS MATERIALS <br />�i SPILL/RELEASE RESPONSE <br />SOLID WASTE FACILITY! VEHICLE[3/WATER <br />FOOD FACILITY�.l <br />/ •- 2 <br />r� ; ^, <br />QUALITY <br />ff ITE MITIGATION <br />POOL I SPA <br />DAIRY <br />LAND USE APPLICATION SITES <br />❑ SEPTIC PUMPER TRUCK I <br />YARD (CHEMICAL TOILETS <br />WASTEWATER TREATMENT PLANT <br />) L <br />i <br />f -r' <br />c <br />,tU <br />` <br />r <br />- <br />❑ HOusING <br />`- <br />1 <br />E7 CUPA <br />HOUSING ABATEMENT <br />r7MOTEL/HOTEL1 <br />L.� <br />CYC% <br />T I <br />- <br />` <br />B <br />CR(CUPA - HAZ-MAT <br />/ 1 <br />f ( { - �%- ✓ �1111 <br />(/ L <br />CHICKEN RANCH /DOG KENNEL <br />MEDICAL WASTE FACILITY <br />n TATTOO/BODY PIERCING <br />I2� WASTE TIRE <br />y <br />SOLID WASTE <br />?J COMPLAINT <br />10 <br />❑ ACCOUNTING <br />OTHER(PLEASE SPECIFY): <br />—BOXED AREA - EHD USE ONLY"' <br />_T <br />