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EHD LOG NUMBER <br /> D T�R CEIVED f l F '1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> DEC 2 5 2015 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: Www.sjgov.org/ehd <br /> TEF.. PU <br /> BLIC RECORDS RELEASE APPLICATION <br /> WAV MkNQ�N�UNIb BUSINESSIAGENCY: <br /> APPLICANT: 2�5( Pc RSS0CIR[ES,11JG. <br /> ADDRESS: V.q. 01C ''37- CITYISTATEIZIP: ��IG VILI C <br /> PHONE(1): )� % TI'A�� PHONE(2): FAX OR E-MAIL: YG�UW,1 <br /> Please allow 10 business days from date of application submittal for the records to be available. LOYn <br /> Staff will contact you to arra e an appointment date and time to review the requested records. <br /> ❑CHECK BOX TO EXPEDITE RE UES - 130 FEE .6AS OR C CK l REQUEST PROCESSED IN 3 BUSINE S DAYS <br /> SIGNATURE OF APPLICANT !(E DATE <br /> Electronic Information: ❑ List❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name city <br /> 1 3Z�� LOCM\S �D S�0(�tl�N N ❑Unit 1 <br /> 2. LQ1U� •� S �fWy \% N fT, pUnit <br /> 3• 3233 1 oOM�S � D S�oc �bN ft6p <br /> /CD <br /> 4 ti�2% • s N �INy%% V4ll S [o( CbN l T�)l�Q� Ci/1� iYV1 C/ ❑Unit 2H <br /> nit vl'b1.1 <br /> $. S 1�� <br /> sr o ooM� �� st�(��oN ON2►)'1 Cf� <br /> w�.y s. 3112 � <br /> nit 4 <br /> 7. %2% S \A %% t�'11�c�c �d �CO(�T�PI V) <br /> B• S `QC��oN ITE MITIGATION <br /> 2�1 1OOM15 �h 1V ^^/n� <br /> 9, C� I'✓1 El nits <br /> 10. <br /> to <br /> Specific Date Range of Information Requested: From <br /> ���555 ENVIRONMENTAL HEALTH DEPARTMENT FILES SOLID WASTE FACILITYIVEHICLE <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING BA ❑FOOD FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑DAIRY,POOLISPA <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑WASTE TIRE <br /> ABOVEGROUNDTANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTE E]MEDICAL WASTE FACILITY ❑PUMPER TRUCK/YARDICHEMICAL TOILETS <br /> [–]TATTOOIBODY PIERCING ❑LAND USE APPLICATION SITES <br /> HAZARDOUS MATERIALS <br /> ® OTHER(PLEASE SPECIFY) <br /> TIERED PERMITTED FACILITY �COMPLAINTIRESPONSE RECORDS ❑ <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM EXCLUDING HOLIDAYS) <br /> 1. List ug <br /> to ten addresses in the space above. Select the type(s)of files from the list above by checking the appropriate <br /> ranges38 or mail to the address I <br /> lw lltnot be accepted.Applications received after 3:00 PITTleast one le type MUST be selected. Fai:::xto 20 will be processed the next businesstday.bove. Address <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 receipt 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$130 deposit prior to review. <br /> —BOXED AREA-EHD USE ONLY- <br /> 0 <br /> >32a 2 <br /> 11 Records provided by Staff-PPR Complete. staff N me: <br />