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.� 1 <br />OCT 2 9 2015 <br />EPMROMMENTAL MEALTH <br />PERMITISERVICES <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue,. Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />P'UBUC RECORDS RELEASE AEPLICATI]ON <br />EHD LOG NUMBER <br />APPLICANT: #C;7 '[I J�9: lN�S �GEPdCY: i% lXi%� i' iCl/ <br />ADDRESS: CITY/STATE/ZIP: <br />PHONE (1) <br />PHONE <br />FACSIMILE: <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- $130 FEE (CASH OR CHECK ONLY)- REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT �jJ / C'411&4_ DATE <br />Electronic Information: ❑ List ❑ Map — Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />Street# <br />Street Name <br />City <br />❑ Unit 1 <br />2. <br />3. <br />❑ Unit 2 <br />4• <br />❑ Unit 2H <br />5. <br />it 3 <br />l2 <br />J 0• <br />7' <br />,'U�/n <br />Ey nit4 <br />8• <br />SITE MITIGATION <br />9. <br />l I <br />❑ Unit 5 <br />10. <br />Specific Date Range of Information Requested: From to :. <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />NDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY [_1 SOLID WASTE FACILITYNEHICLE <br />OTHER CLEANUP SIT. (NON -LOP) ❑ HOUSING ABATEMENT ❑WASTE TIRE <br />aZU DERGROUND TANK (MONITORING/REMOVAL) ❑ FOOD FACILITY [1 DAIRY <br />OVEGROUND TANK ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER TREATMENT PLANT <br />] HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEMICAL TOILETS <br />] TIERED PERMITTED FACILITY ❑ POOL/SPA ❑ LAND USE APPLICATION SITES <br />] TATTOO/BODY 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. 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. <br />Future file reviews by the same applicant may require a $130 deposit prior to review. ***BOXED AREA- EHD USE ONLY*** <br />