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DATERECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> f�F( 13 209 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: v✓wvv.sjgov.org/ehd <br /> r 11A <br /> PUBLIC RECQRDSO RE' EASE APPLICATION <br /> a <br /> APPLICANT: =`� A/i"r'Ii?si� BUSINESS/AGENCY: <br /> ADDRESS: IUL40--)� it fi� C CITY/STATE/ZIP: <br /> PHONE (1): <br /> c!��✓ ``� 2�r% PHONE (2): FAX OR E-rt7AIL:, cc, <br /> Please a`lliow 16 business days from date of applica tion 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 ,,5 e `r1 (��Cz.c— DATE <br /> Electronic information: ❑ List❑ Map—Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street# Street Name City <br /> City <br /> 1. WOO <br /> OO ' �(� t l� CSC �L'I'1 ���(, <br /> 2. El Unit 1 <br /> 3. [;�-Unit 2 <br /> 4. D�Jnit 2H <br /> ©-Unit 3 i(J <br /> Ci. <br /> Q Unit 3HM I l <br /> 7. <br /> nit 4 <br /> 8. <br /> VISITE MITIGATION <br /> 9. <br /> 10. -50, <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> LZ UNDERGROUND TANK(UST)CLEANUP SITE(LOP) [:]MOTELIHOTEL ❑SOLID WASTE FACILITY/VEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) 2-FOUSING ABATEMENT ❑FOOD FACILITY <br /> D't1NDERGROUND TANK(MONITORINGIREMOVAL) 9"A'ASTE T IRE ❑DAIRY,POOLISPA <br /> ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL RWASTEWATER TREATMENT PLANT <br /> V'dAZARDOUS WASTE ❑MEDICAL WASTE FACILITY [:]PUMPER T RUCK/YARDICHEMiCAL TOILETS <br /> HAZARDOUS MATERIALS ❑TATTOO/BODY PIERCING ❑LAND USE APPLICATION SITES <br /> ❑TIERED PERMITTED FACILITY ❑COMPLAINTIRESPONSE RECORDS 21 OTHER(PLEASE SPECIFY)�`lq�`�c/� <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 /> EDRecords provided by Staff-PPR Complete. Staff Name: <br />