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JHN-18-2015 e8:.5SH rtlLun:L;tLn-1-IHyE ENV 2095690295 70:4640138 <br /> `^DATE RECEIVED 0 <br /> _ �"� �AN JOAQUIN COUNTY EHD LOG NUMBER <br /> p '� r��lv tom" ENVIRONMENTAL HEALTH DEPARTMENT yF <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> JAi1 JM?phone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> ;✓.­aP EILIC RECORDS RELEASE APPLICATION <br /> • kf3u1 'dd.ISE irl n <br /> APPLIC 72er t e aM BUSINESS/AGENCY:6;eW/j4 c <br /> ADDRESS: 937 14. 9i&ant As/ CITY/STATE/ZIP: <br /> PHONE(1): a—2 PHONE (2): FACSIMILE:_,-g472C <br /> TENTATIVE*APPOINTMENT DATE: / 2 Time, /y <br /> (Please allow 10 business days from date o}aapneatlon submittal-'Tentative only-must be eonflrmed) <br /> CHECK BOX TO EXPEDITE REQUEST-§.125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT /4 DATE / <br /> Electronic Information: ❑ List❑ Map-Description04.0" <br /> FILE ADDRESS EHD USE ONLY <br /> Street i Street Name qty ' <br /> 1. lie m <br /> 2. <br /> 3. ❑unit 2 <br /> 4. <br /> 5. Unit3 <br /> 6. <br /> -p unn 4 <br /> 7. <br /> 8. <br /> Unit 6 <br /> 9. <br /> 10. <br /> ❑Unit e <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACIL 1 €H�'ICL <br /> ❑ THER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE .g �z! I <br /> ����yyyyyy UNDERGROUND TANK(MONRORINWREMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> EGROUNDTANK v ❑CHICKEN RANCH/DOG KENNEL <br /> AZARDOUS WASTEIHAZARDOUS MATERIALS' ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY .� ❑MO USPS TEL ❑PUMPER TRUCKICATION SI MICAL TOILETS <br /> ❑POOUSPA LAND USE APPLICATION SITES <br /> ❑TATTOO/BODY PIERCING ❑COMPLAINT/RESPONSE 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 uo 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-for additional assistance with file addresses,contact the EHD, Applications received after <br /> 3:00 pm will be processed the next business day. <br /> 2. 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 /> 3. A file that Is actively being worked on by EHD staff may not be Immediately available for review. A new application may be <br /> submitted when the file is available. <br /> 4. Any file not returned In the same condition as released will be reorganized by EHD staff at the e�ense of the applicant. <br /> Future file reviews by the same applicant may require a 8126 deposit prior to review, pXEDAREA EHDiUSEYONt15 <br /> u <br /> a Re Ords,provide'd:by.Staff-PPR Comph e;,stafi Name <br /> ENO 68415 ... ..:. <br /> 81411.2 <br /> Received Time Jan. 18. 2013 9: 53AM No. 2123 <br />