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....- <br /> 07.15 p.m. 05-01-2013 <br /> 1 ". ENVIRONMENTAL HEALTH DEPARTMENT <br /> i MAY 01 2013 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: WWW.sjgov.org/ehd All <br /> Isrit€rtst,�?t1LP17`-,?.'ric:;•!?`t,�l <br /> PUBLIC RECORDS RELEASE APPLICATION V' <br /> APPLICANT: NeVITj BUSINESSIAGENCY: <br /> ADDRESS: CITYISTATEIZIP:�� <br /> PHONE PHONE (2): �7iFACSIMILE: <br /> TENTATIVE'APPOINTMENT DATE: 5�3// Time: <br /> ,.,_,J (Please allow 10 business days from da a of pplication submittal-'Tentative only-must be confirmed) <br /> /I kYCHECK BOX TO EXPEDITE REQUEST- 2 E(C 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 ❑Unit 1 <br /> 1. 11751 <br /> 2. I W Y� y� `l 1'd`nft2 <br /> 3. i3y99 � <br /> 4. l 3 a0 6b <br /> ❑Unit 3 <br /> 5. ) f,12 Ct ,r` l4t�z(� <br /> 6. 5 009 so Cf1�1 ��� �❑Unit4 <br /> 7. 1114 <br /> 8. <br /> ❑Unit 5 <br /> 9. <br /> 10. <br /> jI]Unit 0 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH FILES <br /> ❑UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT SOLID WASTE FACILITYNEHICLE <br /> ,OTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORING/REMOVAL) ❑DOG KENNEL _ ❑DAIRY <br /> ❑HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTELIHOTEL PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TATrooIBODY PIERCING ❑POOLISPA Qj,1AND USE APPLICATION SfrES <br /> ❑ MEDICAL WASTE FACILITY [ COMPLAINT RECORDS E&OTHER(PLEASE SPECIFY) .D_J:5G 0/l� A <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-for additional assistance with file addresses, contact the EHD. Applications received after <br /> 3:OD 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. Anew application maybe <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. <br /> EHD USE ONLY <br /> EHD 4B-e6 <br />