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DTE RECEIVED EHD LOG NUMBER <br /> �,�,���" � SAN �OAQU{�! COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT e^}"'}11 <br /> DEC 0 7. 2015 1868 East Hazelton Avenue, Stockton, CA 95205-6232 �Q�• <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: wvArv.sjgov.org/ehd <br /> t`•MV1P,0N';,�:-^•tTAL HEALT1,' PUBLIC RECORDS RELEASE APPLV�ATIQNI <br /> APPLICANT: i'1jtl�if� BUSINESS/AGENCY: <br /> ADDRESS: �� `�'t �Gt'F-' 'f (�"r' CITY/STATE/ZIP: <br /> PHONE (1): PHONE (2): FAX OR E-MAIL: <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 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Inforro..aflo.": ❑ List ❑ Nfiiap -Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street# Street Name City <br /> V <br /> too ,N J 60 ❑ Unit 1 <br /> ❑ Unit 2 <br /> 4. <br /> ❑ Unit 2H <br /> 5. D"Unit 3 <br /> 6. <br /> ❑:'Unit 3HM <br /> 7. <br /> [;] Unit 4 <br /> 8' ('SITE N11TIGATION <br /> 9. <br /> 1D U Unit 5 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> Q UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MOTEL/HOTEL ❑SOLID WASTE FACILITY([V^EEHII <br /> CLE � -^ <br /> F 'OTHER CLEANUP SITE(NON-LOP) F-1HOUSINGABATEMENT ❑FOOD FACILITY 4— W 6T'- t.#f I f 3 <br /> E'UNDERGROUND TANK(MONITORING/REMOVAL ❑:VASTE TIRE ❑DAIRY,POOL/SPA la—S IZ-1I •1 S <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> i HAZARDOUS IWASTF,,_� ❑MEDICAL WASTE FACILITY ❑PUMPER TRUCK/APD/CHEMICAL TOILETS <br /> QNAZARDOUS MATERIALS ❑TATTOO/BODY PIERCING ❑LAND USE APPLICATION SITES <br /> ❑TIERED PERMITTED FACILITY ❑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 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. <br /> —BOXED AREA -EHD USE ONLY"" <br /> � � t <br /> 0 Records provided by Staff-PPR Complete. Staff Name: <br />