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mair CEIV —� SAN JOAQUIN COUNTY No. 189j EtN, )G NUMBER <br /> OEM <br /> aUa SEP 4 WV2015ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 l5 t�F <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: WwW.Sjgov.org/ehd <br /> 7-NIA RON MENTAL HEALVI <br /> PERIVIT/SERVICES PUBUG RECORDS RELEASE APPLICATION <br /> APPLICANT: ft9k h_) mcbl.�Y11S BUSINESS/AGENCY:S ( 1 �U1�1lG wXkS <br /> ADDRESS: i 9 j � �. kf��-�/) fU� CITY/STATE/ZIP: Stb�`t GFS �l5 <br /> PHONE (1): L'o�l) I(a�-30s5- PHONE (2); FACSIMILE: (W) t/(QF— ZClgy <br /> Please allow 10 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 f CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT 0 ILII(c6�... DATE 9'I'1 -IS <br /> Electronic Information: [-] List❑ Map—Description: <br /> FILE ADDRESS <br /> Street o Street Name Cit, EHD USE ONLY <br /> 1. 3 511 aIIA u 1;ep_ I?-e00 CF5_f-oCj1_tyr1 <br /> a. 32103 GV� IllI Pc�td CE S�i{�TDYI o'Unit I <br /> 3• 130) CAW r&- (Loyd (El SJ'Da/, Vn .- Unit 2 <br /> 4. 3 332 C1n4vu V-a kC¢ A CB S?u�L�.�tn OVnit 2H <br /> t 6• 31-4 L9 LA CkVln 1666 k 0 ctr:tri Unit a <br /> r. 3520 G(il>? VIaV& V-acts( o�it4 <br /> a• 3 SS UIQ t 7J "t, 1200-d ©SITE MITIGATION <br /> 9. 2 lCo T 4n privy CN s_ cyton q lag r� <br /> 10. U"17� Kc � Vr iU7✓ S�(Qt �}1 (]"Unit 5 <br /> Specific Data Range of Information Requested: From to <br /> TTS�II <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> _19 UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ,MEDICAL WASTE FACILITY SOLID WASTE FACILITY/VEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) HOUSING ABATEMENT WASTE TIRE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑FOOD FACILITY DAIRY <br /> . ABOVEGROUND TANK CHICKEN RANCH/DOG KENNEL WASTEWATERTREATMENTPLANT <br /> HAZARDOUS WASTE/HAZARDOUS MATERIALS E]MOTEL/HOTEL PUMPER TRUCK(YARDICHEMICALTOILETS <br /> 0 TIERED PERMITTED FACILITY POOLISPA S,LAND USE APPLICATION SITES <br /> ❑TATTOOIBODYPIERCING 9COMPLAINTIRESPONSERECORDS ❑OTHER(PLEASE SPECIFY) <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(2091484.0138 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 fife not returned In the same condition as released will be reorganited 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. " 50XEO AREA-EHD USE ONLY"` <br /> I r-I . rq.,;A-A tD1.Cf.itf-CCC r`0..,^t^�^ Staff Name• <br /> Received Time=Sep. 17. _2015= 3: 08PM�No. 9598 <br /> ERD 4a-00 711115 <br />