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DAjjF,jCE4y(=Da t EHD LOG NUMBER <br />SAN JOAQUIN COUNTY <br />1 Ei.,IRONMENTAL HEALTH DEPARImENT <br />MAY © 2 13 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />-- Telephone: (209) 468=3420 -Fax: (209) 464=0138 Web: w—'-ov.og1ehd- <br />✓� Elv�;)�.�7�r�PsNf"3Ts��6 HEA+-i'd-i <br />Es PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: C7�0-ow7ryro m BUSINESS/AGENCY: C/I As <br />ADDRESS: a ��. ccy ���5 S�i�`J-�' aac) CITY/STATE/ZIP:�%jClg� �i��e ICA19,5-?3 <br />PHONE (1): G 7q a o-7> PHONE (2): q1t 7/9�a63=l7 FACSIMILE: <br />TENTAT/VE*APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of.application submittal - *Tentative only - must be confirmed) <br />❑ CHECK BOX TO EXPEDITE REQUEST - $125 FEE CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANTS // DATE <br />Electronic Information: [V List ❑ Map - Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />qit 1 <br />Street# Street Name City <br />1. <br />0 R 0 00'�t m <br />tWj; 0MM V, <br />l <br />Me <br />� Unit 2 <br />2• <br />lgsT e ( e r�cn Ne j 4, {& G� � <br />3. <br />r. <br />Unit 3 <br />4' <br />jS� <br />®r 7� V a g— <br />5. <br />Pr S �� L� �� t <br />Unit 4 <br />6.9 <br />7. <br />❑ Unit 5 <br />8. <br />9. <br />❑ Unit 6 <br />110.1 <br />1 <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE FACILITYNE ICLE/, , <br />OTHER CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT ❑ WASTE TIRE <br />UNDERGROUND TANK (MONITORING/REMOVAL) bC ❑ FOOD FACILITY ❑ DAIRY <br />ABOVEGROUND TANK v` ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATERT EATMENT PLANT <br />HAZARDOUS WASTEMAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCK/YARD/CHEMICAL 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 AM-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 />r ltS_r C v S f U �I,s6irve Deadt, <br />0 Records provided by Staff -PPR Complete. Staff Name:c.�✓I�IiU/J�- <br />EHD 46-06 jJ- (,fp- ; i via 5 40t ftqa,,Z ✓'q T 0"-45 T h lt's. t:zo, 914/12 <br />- ---------- ------- -- --- ----------- --------- - - -----. _._.... ----------- <br />7P <br />V <br />/i <br />63Y <br />