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DATE RECEIVED EHD LOG NUMBER SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd PUBLIC RECORDS RELEASE APPLICATION APPLICANT: /.h ed shqk-e-f BUSINESS/AGENCY: ADDRESS: CITY/STATE/ZIP: PHONE (1): ��jl(o2Z S��cJ PHONE (2): FACSIMILE: Please allow 10 business days from date of application submittal for the records to be available. Staff will contact you to arrange an appointment date and time to review the requested records. ❑ CHECK BOX TO EXPEDITE REQUEST - $1?5 FEE (CASH OR CHECK 9NLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OF APPLICANT �,,�I�/� DATE xd2� /Z / 1 d/)` Electronic Information: ❑ List ❑ Map — Description: _ FILE ADDRESS EHD USE ONLY ❑ Unit 1 /A�ozy�3L/ - -- - - /y 3 `f El Unit 2 Street # Street Name City 2. 3. 2l5�v B ce .5'��l�fzm /Aloeyq3i`N, /NO2543W, /25�SN3, In/oL553Sz. Z p ❑ Unit 3 4. 5.6. �etiy-v/ l9ccfh. Er/f�/��Q% ❑ Unit 7. 11207 /pq d-lcd Jl Unit 5 8' — 9. ❑ Unit 6 10. Specific Date Range of Information Requested: From ENVIRONMENTAL HEALTH DEPARTMENT FILES ❑ UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY ❑ OTHER CLEANUP SITE (NON -LOP) OUSING ABATEMENT ❑ UNDERGROUND TANK (MONITORINGIREMOVAL)FOOD FACILITY ❑ ABOVEGROUND TANK ❑ CHICKEN RANCH/ DOG KENNEL ❑ HAZARDOUS WASTEMAZARDOUS MATERIALS ❑ MOTELIHOTEL ❑ TIERED PERMITTED FACILITY ❑ POOLISPA ❑ TATTOOIBODY PIERCING ❑ COMPLAINT/RESPONSE RECORDS to ❑ SOLID WASTE FACILITYIVEHICLE ❑ WASTE TIRE ❑ DAIRY ❑ WASTEWATER TREATMENT PLANT ❑ PUMPER TRUCKIYARD/CHEMICAL TOILETS ❑ LAND USE APPLICATION SITES ❑ OTHER (PLEASE SPECIFY) WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:00PM (EXCLUDING HOLIDAYS) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address indicated above. Address ranges will not be accepted. Applications received after 3:00 pm will be processed the next business day. 2. For assistance in identifying the nature and content of EHD records, please contact EHD at the number noted above. 3. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a $125 deposit prior to review. —BOXED AREA - EHD USE ONLY— Records provided by Staff -PPR Complete. staff Name: EHD 48-06 l 4/28/14