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I 0 004/15/2014 13: 06 FAX 310615454x• 2001/001
<br /> I ■ I
<br /> �N DAT!✓R1 CEfVE D d 60 LOG NUMBER
<br /> ■ SAN JOAQ,UIN COUNTY
<br /> =) ENVIRONMENTAL HEALTH DEPARTMENT p
<br /> 1868 East Hazelton Avenue Stockton, CA 95205-5232 `� t7
<br /> r �.
<br /> APR glephone: (209)468-3420 Fax: (209)464-•0138 Web: www.sjgov.org/ehd ;i f
<br /> ENVIRONMEN, A HEALTH PUBLIC RECORDS RELEASE APPLICATION
<br /> APPLICANTQ BUSINESSIAGENGY: { �
<br /> ADDRESS: CITYISTATE/ZIP: I
<br /> PHONE (1): - [?SS PHONE (2): FACSIMILE: _ s
<br /> TEN *APPOINTMENT DATE: 4 (21A 114Tlme:
<br /> ' ( lease allow 10 business days from dat of app icat n aubmtHal-'Tonfaffve only- nf roust be cood)V
<br /> []CHEC 13OXTO EXPEDITE-REQUEST-$126 FEE(CASH ORCH CK ONLY)-REQUEST PROCESSED IN 3 6 SIN S3 DAYS
<br /> SIGNATURE OF APPLICANT DATE (I
<br /> Electronic Infq atlon: ❑ List El Map—Description:
<br /> FILE ADDRESS EHD USE ONLY
<br /> Street# Street Name City Unit 1
<br /> 1° N 1
<br /> ❑Unit 2
<br /> DM 0
<br /> Unit 3
<br /> s.
<br /> 6.
<br /> Unit a
<br /> 7. YJ
<br /> unit 5
<br /> 1 / unit e•
<br /> Specific Date Ran e t Information Requested: From to
<br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES
<br /> Z,UNDERGROUND (UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FAciuTY SOLID WASTE FACILrryNEHICLE
<br /> lOTHER CLEANUP,11n F(NON-LOP) ❑Houma ABATEMENT WASTE TIRE
<br /> UNDERGROUND F (MONITORINGIREMOVAL) FOOD FACILITY ODAIRY
<br /> AwVEGROLIND TAN CFWCKEN RANCH/DOG KFNNEL D WASTEWATER TREATMENT PLANT
<br /> 21 HAZARDOUS WA E Kk7ARDOUS MATERIALS ❑MOTELIHOTEL C]PUMPER TRUCK/YARDICHENICALTOUTS
<br /> �
<br /> TIa;tED PERNril ACIL" ❑POOLISPA []LAND UsE AFPLICATION SITES
<br /> TATTOoIBDDY P, KING 7COMPWNTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY)
<br /> WELL AND SEP�ii,,C PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAY5)
<br /> 1, List uD to ten addresses In the space above. Select the type(s)of files from the)1st above by checking the appropriate
<br /> box(es). At le a t one file type MUST be selected. Fax to(208)464-0138,(2r mail to the address indicated above, Address
<br /> ranges will not e accepted-for additional assistance with file addresses,contact the EHD. Applications received after
<br /> 3:00 pm will be processed the next business day.
<br /> 2. The EHD will ric tifythe applicafit if any EHD files exist. An appointment for rev4ew will be confirmed approAmately ten(10)
<br /> days atter e t of application, The files will be held for a maximum of five business days for review. Appointments
<br /> should be ac�e duled a=ordingly.
<br /> 3. A file that Is; Ively being worked on by EHD staff may not be imrriedtatelyavailable for review. A new application may be
<br /> submttted w e i the file Is available,
<br /> 4. Any file not r t irned In the same condition as released will bE reorganized by EHD staff at the ex e�nse of the app Il anL
<br /> Future file re 1 ws by the same applicant may require a$125 deposit prior to raview. o7(EJ�i��i'�� IiS�ONC31
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<br /> Received Time Apr, 15. 2014 1 : 16PM No, 5793
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