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DATE RECEIVED SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> RECEIVED ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 (� <br /> SEP 1 1 20ITelephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> nn�7/s " PUBLIC RECORDS RELEASE APPLICATION <br /> APPLLI AIA ,C,j'Jr k�f 'o_ BUSINESS/AGENCY: <br /> ADDRESS: 3' ��fQ CITY/STATE/ZIP: C �U <br /> PHONE (1): PHONE (2): FACSIMILE: <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 REQUES - FEE SH O�_CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> 19 <br /> SIGNATURE OF APPLICANT X DATE <br /> Electronic Information: ❑ List ❑ Map— Description: <br /> FILE ADDRESS <br /> Street# Street Name City EHD USE ONLY <br /> 1. S4q L9 I ft"Its —c <br /> 2. <br /> E] Unit 1 <br /> 3. 11 <br /> fOv,t�p,hC.�, ❑ Unit 2 <br /> 4. <br /> ❑Unit 2H <br /> 5. <br /> 6. y <br /> Dlu�It33 <br /> 7. 0,41:4 <br /> 8. <br /> SITE MITIGATION <br /> 9. <br /> 10. <br /> ❑ Unit 5 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY E]SOLID WASTE FACILITYNEHICLE <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 ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTEL/HOTEL ❑PUMPER TRUCKIYARDICHEMICALTOILETS <br /> TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> TATTOO/BODY PIERCING E COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM (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. ***BOXED AREA-EHD USE ONLY*** <br /> Nw C'k LOP N &AL 2e k {or t*tril F . <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHO"-e6 <br /> ]It I[5 <br />