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dA C VE itusif <br /> ad EHd LOG NUMBER <br /> TAREZ� 1011 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> j&eW?t0NA4EN'TAL}fMTH 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> qW F'EIAIT/SE R+CES Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd 505 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: I/I rQ BUSINESSIAGIENCY: <br /> ADDRESS: 44 CITYISTATEIZIP: �...� <br /> PHONE(1): / '- PHONE(2): FAX OR E-MAIL: r C <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 EXPEDITZ;_w. <br /> $139 FE (CASH OR HE ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE__-, ,g <br /> 1. List u to ten_addresses in th Select the (s)of files from the list below 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$139 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List[] Map—Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES EHD USE ONLY <br /> ;` <br /> i�tiNOERCROUND TANK(UST; Street# .Street Name City - <br /> J CLEANUP SITE(LOP)THER CLEANUP SITE(Naw-LOP) �,j//^rd` 'I ''1i,A,�1 t-✓--l't"J/4+{/'�I 6T <br /> �❑Y <br /> CONSI IMER <br /> -T r�� �( Uy. " ) � <br /> TODill <br /> / lIlu <br /> TAIARDOUS WASTE 137 <br /> IERED PERMITTED FACILITY J I: 0 1NRY <br /> �/'� <br /> ABOVEGROUND TANK !+ <br /> ST (MONITORING IREMOVAL 4111t1j ! C 7 k�[3 PWS �I J <br /> HAzARDovs MATERIALS 3 �' , ✓ /)7/ �I yry <br /> PILURELEASE RESPONSE 6f i V J "'--� /�r� rpbf I <br /> SOLID WASTE FACILITY I VEHICLE (<� V4'ATER 4uAUTY <br /> FOOD FACILITY �� 1� l•�9-- <br /> Fj POOL I SPA <br /> SITE MITIGATION <br /> Ej DAIRY 5 <br /> 0 LAND USE APPLICATION SITES <br /> ®SEPTIC PUMPER TRUCK I HOUSING <br /> YARD I CHEM1cAL TOILETS 8 <br /> WASTEWATER TREATMENT PLANT <br /> ©HOUSING ABATEMENT T <br /> CUPA <br /> MOTEUH07rL <br /> CHICKEN RANCH I DOG KENNEL - <br /> 11 CUPA-UST <br /> MEDICAL WASTE FACILITY <br /> Q TATTOOIBODY PIERCING <br /> WASTE TIRE SCUD WASTE <br /> O<OMPLAINT B <br /> OTHER(PLEASE SPECIFY): <br /> W Q ACCOLINTING <br /> "`BOXED AREA-EHD USE ONLY"' <br /> T <br /> 1~ <br /> © Records p vide by Staff-P R Complete. Stan Name: rr J <br /> EHD..-. czco /.� 1}X101 q-- 18,77- � r�-u- <br />