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08/20/2014 14:47 FAX <br />FRY <br />�Y F <br />DATE RECEIVED �°�'' <br />zs' SAN JOA tJIN L M <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />AUG 210T&Qhone: (209) 468-3420 Fax: (209) 464-0138 Web: www,sjgov.org/ehd <br />R,nn�VT�LHEPAfIBLIC RECORDS RELEASE APPLICATION <br />FFRM1 yr_nv,ur- <br />APPLICA�JT: _gf o I '�� <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. ,V/6��•}`%�{ <br />�y CHECK SOX TO EXPEDITER EST- $125 FEE (CASH OR CHECK ONLY) -REQUEST PROCESSED IN 3 BUSINESS DAYS IZC%" j <br />SIG/NATURE OF APPLICANT ¢ DATE <br />pC <br />Electronic Information: ❑ List ❑ Map— Description: <br />FILE ADDRESS <br />BUSINESS/AGENCY- � Co-nsu I+, <br />ADDRESS: <br />Street # <br />Street Name <br />6 500 CITYISTATE/ZIP: Ie,_Co <br />PHONE (1): Jca <br />0• <br />__ A). Hwn ! !�. <br />PHONE (2): _)ap •`14-0 f3Q93 FACSIM( : <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. ,V/6��•}`%�{ <br />�y CHECK SOX TO EXPEDITER EST- $125 FEE (CASH OR CHECK ONLY) -REQUEST PROCESSED IN 3 BUSINESS DAYS IZC%" j <br />SIG/NATURE OF APPLICANT ¢ DATE <br />pC <br />Electronic Information: ❑ List ❑ Map— Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />❑ unit 1 <br />Street # <br />Street Name <br />City <br />1. <br />__ A). Hwn ! !�. <br />„, <br />e-tI.AP �- n;cc.rjp <br />la P <br />IiMi 45 iMM Unit2 <br />,oc 'iw <br />Unit 3 <br />3`i 8-7 <br />n) I <br />//'�� �^� �j �j j <br />42 <br />�g c. w. <br />. <br />nl! 4 <br />+ zaa35j; <br />T. <br />�— <br />❑ units <br />s. <br />9. <br />Unit S <br />10. <br />Specific Date Range of Information Requested_ Fromof OD �o tD <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />j:'7,�� <br />I� INDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE FAC0.fTYIVEHICLE <br />�T�,6THER CLEANUP SITE (NON -LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br />,� uNDERCROU ND TANK (MONITORINGIREMOVAL) ❑ FOOD FACILITY ❑ DAIRY <br />MIABOVEGROUND TANK ❑ CHICKEN RANCH[ DOG KENNEL ❑ WASTEWATER TREATMENT PLANT _0A <br />[ lLuARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTEUHOTEL ❑ PUMPER TRUCKIYARDICHEMICAL TOLETS <br />❑ TIERED PERMITTED FACILITY ❑ POCUSPA ❑ LAND USE APPLICATION SITES <br />❑ TATTOOIBODY PIERCING ❑ COMP WNTIRESPONSE 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 ton addres es In the apace above. Select the type(s) of files from the list above by checking the appropriate <br />box(ea). At least one file type MUST be selected. Fax to (2091464-0138 or mall to the address Indlcated 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 racelpt 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 applicant. <br />Future file reviews by the same applicant may require a $125 deposit prior to review, "'BOXED AREA - EHD USE ONLY" <br />QJ'21 1 r j r 21 r r I LLL <br />❑ Records provided by Staff -PPR Complete. Staff Name: <br />EHD 46-06 <br />Received Time Au; -20. 2014 1:51PM No.6814 <br />4ae14 <br />