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SID <br /> SAN JOAQUIN COUNTY MEHD LOG NUMBER <br /> MAY E j 2013 ENVIRONMENTAL HEALTH DEPARTMENT n r <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 v <br /> 0 <br /> VIRON w9EN.Al HEALTH Telephone: (209)468-3420 Fax:(209)464-0138 Web:WWW.SjgOV.org/ehd <br /> P[RIU'.T1CrUtn.rcc PUBLIC RECORDS RELEASE APPLICATION 11 FII F COPY <br /> APPLICANT. Dif-90 VgSiU BUSINESS/AGENCY:,.4P0{qEAVilaaAh{gj �I/'ev xnG <br /> ADDRESS: I72 Ctrilli SkfSVCfe 103 CITY/STATE/ZIP: (0/'orll � Y2Jr0 <br /> PHONE(1): .151- ]3(.- 5334 PHONE(2): FAX OR E-MAIL: V4S1 <br /> �tZ�vr teilnV.ConL <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-$139 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED 1N 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT .�/.(ap /E'(l�d,ty DATE OS�26�Z017 <br /> 1. List uo to ten addresses in the space below. Select the type(s)of files from the list below by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(2091464-0138 or mall 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 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. / f <br /> Future file reviews by the same applicant may require a$139 deposit prior to review, lac/ <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑List❑ Map-Description: <br /> Speck Date Range of Information Requested: From 811 to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES EHD USE ONLY <br /> &�ONDERGRGam TANK(UST) Street# Street Name <br /> City <br /> CLEANUP SITE(LOP) ❑CDNSWIER <br /> 'ETHER CLEANUP SITE(NON-LOP) 3y OUek Cretk Drive S+0CK+0n <br /> ©'HAZARDOUS WASTE <br /> &JMERED PERMITTED FACILITY 2 <br /> RASOVEGROVNO TANK <br /> QAJST (MONITORING/REMOVAL) ❑PWS <br /> [ 4MAZAR000S MATERIALS S <br /> &8PIULRELEASE RESPONSE <br /> ❑SOLID WASTE FACILITY I VEHICLE 4 WATER QUALITY <br /> 0 FOOD FACILITY <br /> POOL/SPA _ <br /> DAIRY 6 SNE MmGAnON <br /> ❑LAND USE APPLICATION SITES <br /> SEPTIC PUMPER TRUCK/ <br /> 6 ❑HOuwNG <br /> YARD/CHEMICAL TOILETS <br /> �ASTEWATER TREATMENT PLANT <br /> M HOUSING ABATEMENT T UPA <br /> ❑MOTEL/HOTEL <br /> ❑CHICKEN RANCH/DOC KENNEL <br /> �EDKCUPA-UST AL WASTE FACILITY S / <br /> TATTpp160UT PIERCING <br /> ❑WASTE TIRE 1 W.E <br /> 8 <br /> (A�i'COMPWNT <br /> OTHER(PLEASE SPECIFY): <br /> 10 ❑AfIAVMIUG <br /> "'BOXED AREA-EHD USE ONLY" <br /> 5-X2-1-7. a0n c, E i e Lac "le - /7n. <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 48-06 <br />