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DA*RECEj N. ,a <br /> �, Z!_ • SAN JOAQUIN COUNTY • EHD LOG NUMBER <br /> .JUL. 5 2013 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> None:(209)46823420-Fax. (209)464-0138-Web: www.sjgov.orgrhd— <br /> PUBL/II�C RECORDS RELEASE APPLICATION r <br /> APPLICANT: C �S�n,V .er (��,1y�1 BUSINESS/AGENCY: <br /> ADDRESS: LS `N4 S� �r1 c, p q.aA CITY/STATE/ZIP: <'en Qr QA- cfggo <br /> PHONE (1) Z(G - PHONE (2): FACSIMILE.- <br /> TE <br /> ACSIMILE: <br /> TE�VESAPPOINTMENTDATE: <br /> Time: <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE RE T- 125 FEE(CA C ECK Y)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT C DATE05 <br /> Electronic Information: ❑ List❑ Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> lI Street# Street Name city ❑ Unit 1 <br /> l` 1 Ltt0 .St�: �b'e f l_ ( m ,No cols <br /> U 2. So.��n ecx�+tar S2 I_od m �, _ �yP <br /> 3. �JG <br /> 4. 1 / <br /> ,�I Unit 3 / <br /> 5. <br /> 6. Unit4 6i(� <br /> 7. <br /> 8.. <br /> ❑ Unit6 <br /> LL <br /> Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES — <br /> UDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY SOLID WASTE FACIU YIVE77ICLE <br /> yOTHER CLEANUP SITE(NON-LOP) [:1 HOUSING ABATEMENT ❑WASTE <br /> [J UNDERGROUND TANK(MONITORINGIREMOVALJ4 ❑FOOD FACILITY ❑QAIRY <br /> Z OVEGROUNDTANK (7` ❑CHICKEN RANCH/DOG KENNEL ['WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTEIHAZARDOUS MATERIALS V(, ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOOIBODY PIERCING ❑COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AMI-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List up to ten addresses in the space above. Select the type(s)of files from the list above 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-for additional assistance with file addresses, contact the EHD. Applications received after <br /> 3:00 pm will be processed the next business day. <br /> 2. 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 /> .3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be <br /> submitted when the file is available. <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 /> _I�-l� • v � r uAj �. <br /> g 13' e <br /> b 50D l uu <br /> 33140 tDl2 <br /> ❑ Records provided by Staff-PPR Complete. taff Name: <br /> EHD 48-06 <br /> 914112 <br />