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DATE-RECEIVED - EHD LOG NUMBER <br /> - — - SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT t <br /> DFC 2015 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: vvvvvv.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUS{NESSIAGENCY: <br /> ADDRESS: L)4(" }-; kms Ci�'r C ftp. ��f CITY/STATE/Z[P: <br /> U � i <br /> PHONE (1): 1-7-7( f �� �'}�7-w PHdNE (2): FAX OR <br /> Please allow 1C 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 / vt DATE <br /> I Electronic information: ❑ List❑ Map-Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street# Street fume City <br /> EJ unit 1 <br /> 2. <br /> 3. V�'L"it 2 <br /> 4. O--Unit 2H <br /> 5. ©,Gnit 3 . rr <br /> � ! u <br /> �/ r I <br /> E. Lr,unit 3HM <br /> 7. <br /> nit4 <br /> 8. <br /> E� ITE MITIGATION <br /> 9. <br /> F ;'�Vl 50 2,1init 5 <br /> Specific Date Range of Information Requested: From to <br /> / ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> Ej UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MOTEL/HOTEL ❑SOLID WASTE FACILITYNEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) - IOUSING ABATEMENT ❑FOOD FACILITY <br /> D'(1NDERGROUND TANK(MONITORING/REMOVAL) g'CrASTE TIRE ❑DAIRY,POOUSPA <br /> DI /ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL WASTEWATER TREATMENT PLANT <br /> �TAZARDOUS WASTE F-1MEDICALWASTE FACILITY [:1 PUMPER T RUCKIYARD/CHEMICAL TOILETS <br /> AZARDOUS MATERIALS ❑TATTOOIBODY PIERCING ❑LAND USE APPLICATION SITES <br /> ❑TIERED PERMITTED FACILITY ❑COMPLAINT/RESPONSE RECORDS OTHER(PLEASE SPECIFY)__C�,P4 <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:0OPM(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 /> ❑ Records provided by Staff-PPR Complete. staff Name: <br />