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DK1 Y CIJ SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> iNVIRONMENTAL HEALTH ARTMES <br /> FEB Q g 201? <br /> 1868 East Hazelton Avenue, Stockton, <br /> CA 95205-6232 <br /> f Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION 1 <br /> )APPLICANT: }QAII�S �OI111S�bt� BUSINESS/AGENCY: 'FFjE CrIO2 A <br /> ADDRESS: ;aje I West p6LA4 HiOnig, CITYISTATE/ZIP: Cl� q0415 <br /> PHONE(1): (�lh) Q,54'(0300 PHONE (2 : (3(0�5_ff:i Cj �' FA R E-MAIL: L <br /> Please allow 10 business days from date of application submittal for the records to bd availabi . lo beH, 0M <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$139 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> 1. List up to ten addresses in the space below. Select the type(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 � u5� CS- <br /> HEALTH DEPARTMENT FILE ADDRESS EHD USE ONLY <br /> FILES <br /> UNDERGROUND TANK(UST) Street# Street Name City1�, ��( Q CONSHMER 1 <br /> CLEANUP SITE(LOP) ' OW E R" <br /> Q Q Loc <br /> I/�, U� • <br /> OTHER CLEANUP SITE(NON ) U(� VF(j <br /> YLHAZAROOUS WAST .,f^ DAIRY <br /> if— <br /> TIERED PEmmmdi 14Y\%` 2 <br /> $&ASOVEGROUND TANKK"`2 �A� PWS <br /> UST (MONITORING/RE:MdL <br /> ) <br /> ) a <br /> JZ HAZARDOUS MATERN <br /> l%SPILL/RELFASE RESPONSE - WATER QUALITY <br /> ❑SOLID WASTE FACILITY I VEHICLE 4 <br /> rl FOOD FACILITY SITE MITIGATION <br /> ❑POOL/SPA <br /> ❑DAIRY 5 <br /> LAND USE APPLICATION SITES HOUSING <br /> ❑SEPTIC PUMPER TRUCK/ B <br /> YARD/CHEMICAL TOILETS <br /> WASTEWATER TREATMENT PLANT CUPA <br /> ❑HOUSING ABATEMENT r <br /> MOTEUHOTEL CUPA-UST <br /> CHICKEN RANCH/DOG KENNEL <br /> 8 <br /> MEDICAL WASTE FACWTY <br /> TATTOCBODY PIERCING Ej SOLID WASTE <br /> WASTE TIRE 9 <br /> fRj_COMPLAIw <br /> ®OTHER(PLEASE SPECIFY): Accourrrlrvc <br /> welt �Ho ,D <br /> I --BOXED AREA-EHD USE ONLY' <br /> ❑ Records provided by Staff-PPR Complete. staff Name: <br /> EHD 4e-D6 <br />