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DATE RECEIVED Z�91 '°N NVZO : l �M '�l '"N MIM P;AI, 3;� <br /> -SAN JOAQUIN COUNTY <br /> RECEIVED ENVIRONMENTAL HEALTH DEPARTMENT <br /> 8 8 E <br /> 1 <br /> NOV 2012 6 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 466-3420 Fax: (209) 464-0138 Web. v'rvvw-sjgov.Qr9/6hd <br /> ENVIRONMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: C k 0.r C5 G OLr. C10 l 13USINESSIAGENCY: f\j �? <br /> ADDRESS: S 8vt= S f L2 A CiTYISTATezip: 1 <br /> PHONE (1): 2oq -3 zI - 2C&.r PHONE (2): fAGSIMILE: ��' �a�q� a6 4 8 <br /> TEIVTArlvE*APPOINTMENT DATE- L1 —�.'$ V.L Time: "36 <br /> (Please allow 10 business days from date of apPlicatlon submittal-'Tentative only-must be confirmed} <br /> ❑ CHECK BOX TO EXPEDITE REOUE -$125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE pf/-I <br /> Electronic information-, ❑ Llst E] Map Descriptlon: <br /> FILE ADDRESS EHD LOSE ONLY <br /> Street A! Street Name city <br /> 0 Unit t <br /> �� �. al0a� S • 1�1 � i�tr c� . �� -- �g— �� <br /> i�13 lI� a- 0 R ODQ � <br /> J ri III{�C�p d, P l- )] Unit2 <br /> 3. <br /> 021 ahCO- <br /> 4. 1z 0q 5 ►A� els wr I�c� , nit <br /> 5- al 1co KO a. l�r7r/. 1 <br /> 6, a(4 5O &I a; S+ <br /> nit d <br /> 7. <br /> Ay-e. <br /> �_A <br /> /-21 <br /> Specific Data Range of Information Requested. From a r it 6 <br /> UNVIRONMENTAL HEALTH DEI <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FA ✓U <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEIVIS <br /> �UNDERGRBUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY <br /> ABOVEOROVND TANK ❑CHICKEN RANCH/DI ��.J/GS <br /> ZHAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELJHOTEL 1LE;TS <br /> ❑TIERED PE:RNTTED FACILITY ❑POOL,ISPA <br /> ❑TATTOO/BODY PIERCINi3 ❑COMPLAINIV ESPON <br /> WELL AND SEPTIC PERM17 RECORDS ARE AVAILABLE FQR REVIEW: M(r,.,,,,, <br /> 1. List_u ten addE2*ses 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_ Faxto 09 464-0138 or mall to the address Indicatad above_ Address <br /> ranges will not be accepted-for additional assistance with file addrosses,contact the EHD. Applications received after <br /> 3:00 pm will be processed the next business day. <br /> 2. The EMD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) <br /> days altar reeelpt 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 sniff may not be Immadlaely available for rsview. A new application may be <br /> submitted when the file Is available. <br /> Any <br /> e not returned in the same condition au raleased will be reorganized by EHD <br /> 4• i file reviews by the same applicant may require a$125 deposit prior o review.staff at the expense <br /> Future of the applicant <br /> "• I .:'.' :..•..+..:I:-"'f-II�A::I'.' .I� d'....y1.' ''.1,,,�.....:.':..,... ,.I. ,I _ :.,I� r,y», S. :.li•., <br /> .4" ::!" , ' 77, ••75' .€ars.. <br /> .ri.i :.p:f.::'•.I.i.:n' ..1.'Irl:L,u .:r.Yr <br /> •4•y ..5.: .L:. <br /> END 48-06 <br /> GF/TF•FQPA7. GT:AT 7TFI7/F-T./TT ..$ <br />