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DATE RECEIVED EHD LOG NUMBER <br />�— SAN JOAQUIN COUNTY - <br />EM.o(ONMENTAL HEALTH DEPARTMr-NT �. <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 U, A I It., <br />It <br />NOV 2 2W�) Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />L-AVIRONMENTAL PUBLIC RECORDS RELEASE APPLICATION <br />&. <br />APPLICANT: �'�, a%is� � n ���> BUSINESS/AGENCY: C/ - S C - <br />ADDRESS: ` ca r-�� , �-^ �o<, +�Ei.N r -,.t,- - CITY/STATE/ZIP: y - � -' ,Sri ki. �� j C!"114710 <br />PHONE (1): PHONE (2): 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 EE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT DATE %i- ?3-- 15 <br />Electronic Information: ❑ List ❑ Ma'p­- Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />to � ,p��/17�-- <br />Street # <br />Street Name <br />City <br />,Q UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />MEDICAL WASTE FACILITY <br />Q <br />❑ Unit 1 <br />2. <br />❑ <br />�' <br />3. <br />UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ <br />FOOD FACILITY <br />❑ Unit 2 <br />4. <br />ABOVEGROUND TANK <br />❑ <br />CHICKEN RANCH/ DOG KENNEL <br />❑ Unit 2H <br />5.!� <br />❑i HAZARDOUS WASTE/HAZARDOUS MATERIALS <br />❑ <br />MOTEL/HOTEL <br />0`Unit 3 <br />PI IMPFR TRI 1CKrYARD!CHEM!CAI TO! FTC <br />❑ TIERED PERMITTED FACILITY <br />❑ <br />POOL/SPA <br />T. <br />USE APPLICATION SITES <br />© TATTOOIBODY PIERCING <br />❑ <br />❑ Unit 4 <br />8. <br />OTHER (PLEASE SPECIFY) <br />❑ SITE MITIGATION <br />9. <br />E34Jnit 5 <br />10. <br />Specific Date Range of Information Requested: From <br />to � ,p��/17�-- <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />,Q UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />MEDICAL WASTE FACILITY <br />Q <br />SOLID WASTE FACILITYNEHICLE <br />M OTHER CLEANUP SITE (NON -LOP) <br />❑ <br />HOUSING ABATEMENT <br />❑ <br />WASTE TIRE <br />UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ <br />FOOD FACILITY <br />❑ <br />DAIRY <br />ABOVEGROUND TANK <br />❑ <br />CHICKEN RANCH/ DOG KENNEL <br />❑ <br />WASTEWATER TREATMENT PLANT <br />❑i HAZARDOUS WASTE/HAZARDOUS MATERIALS <br />❑ <br />MOTEL/HOTEL <br />❑ <br />PI IMPFR TRI 1CKrYARD!CHEM!CAI TO! FTC <br />❑ TIERED PERMITTED FACILITY <br />❑ <br />POOL/SPA <br />❑'LAND <br />USE APPLICATION SITES <br />© TATTOOIBODY PIERCING <br />❑ <br />COMPLAINVRESPONSE RECORDS <br />"0 <br />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 />11 LQ Records provided by Staff -PPR Complete. Staff Name: !� ; ,.,q , ( / <br />=WM AQ ng _i <br />