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DATE kECt:Ivt;U VEHD LOG NUMBER <br /> SAN JOAQUIN COUNTY Y <br /> I. EN.;;ONMENTAL HEALTH DEPARTME;,T q' 1 j <br /> t� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 �` <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: v✓vrw_sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION A <br /> APPLICANT: Qn= s(xti }Q� BUSINESS/AGENCY; <br /> ADDRESS: o;w_ F CITY/STATETL(P: <br /> PHONE (1): d0 _9/ l $3Gf THONE (2): FACSIMILE: / <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 buslness days from date of application submittal--Temadve only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST.S125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List❑ Map–Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name city <br /> j I 1( I : t pUnd 7 <br /> z. <br /> . ❑Unit2 <br /> 3. <br /> 4. <br /> ,❑Unit 3 <br /> 5. <br /> 6. &oIt 4 <br /> 7. <br /> 8. <br /> ❑Unit 5 <br /> 9, <br /> 10. <br /> ❑Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENTFILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY 3. <br /> NoN-LOP ❑WAS WASTE FACRRYNEN LE <br /> OTHER CLEANUP SITE <br /> ( ) ❑HOuaIHO ABATEMENT F]WASTE TIRE�(' fjl� Q)/'(t/70 i <br /> UNDERGROUND TANK(MONITORIHGIREMOVALK ❑FOOD FACILrrY ❑DAIRY❑ V. <br /> ABOVEGROUND TANK <br /> CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTE/HAZARDOUS MATERIALS ❑MOTELMOTEL ❑PUMPERTRUCK(YARDICHFmicALToiLETS <br /> ❑TIERED PERMnTED FACILITY ❑POOUSPA ❑LAND USE APPLICATION SITES <br /> ❑TATToolEODY 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 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(2091464-0138 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 it any EHD Ales 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 END 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 expense of the applicant <br /> Future file reviews by the same applicant may require a$125 deposit prior to review. —BOXED AREA-ElD IJ SE ONLY <br /> e t o <br /> -f Lf" -f a c0. <br /> ❑ Records provided by Sta"PR Complete. staff Name- <br /> END" <br /> ame:END"8 G 9l4n2 <br /> Received Time Dec. 23, 2013 1 : 11PM No- 4862 <br />