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I■ <br />I.OP3901253 13:53:56 08-24-2015 1/1 <br />I■ <br />I ■ DATE RECEIVED EHD LOG NUMBER <br />I■ <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 />6 <br />PUB,,L[[I__C�� RECORDS RELEASE APPLICATION <br />APPLICANT: &&Ac' BUSINESSIAGENCY: 6n>.p��P_ GAt'es I l i6_ <br />ADDRESS: I EtG,i(-ERPWS >~!p►� - �Stil)'( qO CITY/STATErz1P:)LLe ; CA 9%P <br />PHONE (1): �o PHONE (2): _a[9 -Z4-2,+ FACSIMILE: 91to - -70U:aa+. <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 REQU ST- $130 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS/ DAYS <br />SIGNATURE OF APPLICANT CA _ � / f DATE '612' 1 )S <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 />�tTii ACACIA hb5- <br />�)P� � <br />3. <br />f `!' �.1 i <br />��� .� <br />=-r <br />1 0 f <br />ACEI t(tC n1t2 <br />4. <br />v v <br />rq <br />'OM ❑ Unit 2H <br />5. <br />J_(� <br />Unit 3 <br />6. <br />7. <br />[] Unit 4 <br />8. <br />eSITE MITIGATION <br />9. <br />❑ Unit 5 <br />10. <br />Specific Date Range of Information Requested: From ALL- to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />*UNDERGROUND TANK (UST) CLEANUP SiTE (LOP) ❑ MEDICAL WASTE FACILITY ❑ SOLID WASTE FACILiTYIVEHICLE <br />THER CLEANUP SiTE (NON -LOP) ❑ HOUSING ABATEMENT ❑ WASTE TIRE <br />12 NDERGROUND TANK (MONITORING/REMOVAL) ❑ FOOD FACILITY ❑ DAIRY <br />ABOVEGROUND TANK ❑ CHICKEN RANCH/ DOG KENNEL E] WASTEWATER TREATMENT PLANT <br />HAZARDOUS WASTEIHAZARDOUS MATERIALS F1MOTELIHOTEL ❑ PUMPER TRUCKNARDICHEMICAL ToILETs <br />TIERED PERMrrTED FACILITY r� <br />❑ CISPA E]LAND USE APPLICATION SITES <br />❑ TATTOOIBODY PIERCING COMPLAINTIRESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <br />WELLAND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:OOPM (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 />❑ Records provided by Staff -PPR Complete. Staff Name: <br />EHD 48-06 <br />Received Time Aug.24. 2015 1:33PM No -9402 <br />