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DATA RECEaVE. •. � .,_,., EHD LOG NUMBER [' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART EN �. �1E20l5 1868 East Hazelton Avenue, Stockton, CA 952113. t+ C Telephone: (209) 4168-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd PUBLIC RECORDS RELEASE APPLICATION APPLICANT: Sovyu_. ''LG CS�`�`� } `� � -BUSINESS/AGENCY: ADDRESS: N-19 ('3n1/Ak_ LL CITY/STATE/ZIP: ��O.Q t g ; PHONE (1): PHONE (2): ?S= S 537.3 FAX OR E-MAIL: clr,+�oOJ'(tiys ur-ct9rr °. Please allow 10 business days from date of application submittal for the records to be available, a r'�— Staff will contact you to arrange an appointment date and time to review the requested records. KCHECK BOX TO EXPEDITE REQUEST - $130 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OF APPLICANTDATE 12-1 Z J Electronic Information: [List ❑ Map —Description: FILE ADDRESS END USE ONLY Street # Street Name City 1. 27 f � a.s• Hit;to tie, sb(_�hyl, ❑ Unit 1 1 ` `✓' 2. S yvi n 3123 �tr1 U '� S 1 ❑ unit 4. 33 ( D n- _ - oz y 2H 5. a 1 l n t\ E- S �` tl Y-) /yJ nit 3 6. as y [j Unit 3HM 7' E;1 nit 4 $' E3 SITE MITIGATION 9. El Unit 5 10 Specific Date Range of Information Requested: From 1170 to 20 t�— ENVIRONMENTAL HEALTH DEPARTMENT FILES ® UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MOTELIHOTEL ❑ SOLID WASTE FACILITYNHICLE ® OTHER CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT ElFOOD FACILIT�e5 ffI r (i rl UNDERGROUND TANK(MONITORINGIREMOVAL)WASTE TIRE [IDAIRY, POOL/SPA •I c4O \t/-5 X IZ- 7-15 ® ABOVEGROUND TANK v ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER TREATMENT PLANT ® HAZARDOUSWASTE '� ❑ MEDICAL WASTE FACILITY ❑ PUMPER TRUCKIYARDICHEMICAL TOILETS HAZARDOUS MATERIALSG� ❑ TATTOO/BODY PIERCING ❑ LAND USE APPLICATION SITES ❑ TIERED PERMITTED FACILITY ❑ COMPLAINT/RESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:00PM (EXCLUDING HOLIDAYS) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected, Fax to (209) 464-0138 or mail to the address indicated above. Address ranges will not be accepted. Applications received after 3:00 pm will be processed the next business day. 2. For assistance in identifying the nature and content of EHD records, please contact EHD at the number noted above. 3.. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense oft the applicant. Z7iCJAg14 4' Future file reviews by the same applicant may require a $130 deposit prior to review. ►Z 7-15 �'� j �, F� fcD ***BOXED AREA - EHD USE ONLY*** swd) vw;