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1 W04/15/2014 13: 06 FAX 310615454:; 0001/001
<br /> IN: DATE RECMVED Irl EHD LOG NUM9ER
<br /> RE� SAN JOAQUIN COUNTY„ 11F C
<br /> -rEWED ENVIRONMENTAL HEALTH DEpAR'TMIF—NT �-•.,, � , • •, ,� , �*
<br /> 1868 East Hazelton Avenue, Stockton, CA 95205-5232 -
<br /> APR Nlglephone: (209)468-3420 Fax: (209)4640138 Web: www.sjgov.org/ehd '
<br /> ENVIRONMEN, HEALTH PUBLIC RECORDS RELEASE APPLICATION
<br /> APPLICANT:,,3� BUSINESS/AGENCY: Pprm�. —
<br /> ADDRESS: CITYISTATE/ZIP': t
<br /> PHONE (1): '7� �4�- RHONE (2): FACSIMILE: _ s
<br /> TENT; IVE*APPOINTMENT DATE: L- Tlme: 16 - 3Q
<br /> ( lease allow 10 business days from da14 of app icatlon submittal-=Tanfaflve only-must be conflrmod)
<br /> [] CHEC BOX TO EXPEDITE REQUEST-$126 FEE(CASH OR C CK ONLY)-REQUEST PROCESSED IN 3 8 SIN SS DAYS
<br /> SIGNATURE O APPLICANT DATE (I
<br /> Electronic InN atlon: ❑ List❑ Map—Description:
<br /> FILE ADDRESS EHD USE ONLY
<br /> Street# Street Name City Unit 1
<br /> ❑Unit 2 d
<br /> v
<br /> o m
<br /> 4.
<br /> Unit 3
<br /> 6.
<br /> _ —'O-nit 4
<br /> 7.
<br /> a" __,• _ 171 Uhit 5
<br /> ( / Unit 6•
<br /> Specific Date Ran e f Information Requested: From to
<br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES
<br /> ,UNDERGROUND (UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY SOLID WASTE FAcuryNEHICLE
<br /> MER CLEANUP I (NON-LOP) ❑Houma ABATEMENT WASTE TIRE
<br /> UNDERGROUND (MONITDWNGIREMOVAL) El FOOD FACILITY RDAIRY
<br /> AwYEGROUND ❑CWCKEN RANCHI DOG KENNEL ❑WASTEWATER TREATMENT PLANT
<br /> HAZARDOUS WA E KAZARDOUS MATERIALS ❑MOTFUHOTEL C]PUMPER TRUCKNAROICHEMICALTOILEis
<br /> TIERED PERAIIT11r I ACILUY ❑POOUSPA ❑LAND USE APPLICATION SITES
<br /> LJ TATTOOIBDDY PI1 R ING 7COMPLAINORESPONSE RECORDS ❑OTHER(PLEASE SPECIFY)
<br /> WELL AND SE PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS)
<br /> 1. List uD to teh ai dresses In the space above. Select the type(s)of files from the IM above by checking the appropriate
<br /> i ox(es). At a t one file type MUST be selected. Fax to(208)464-0138 Qr mail to the address indicated above, Address
<br /> ranges will not ie accepted-for additional assistance with file addresses,contact the END. Applications received after
<br /> 3:00 pm will to processed tha next business day.
<br /> 2. The EHD will ric tifythe applicant if any END(Iles exist. An appointment for review will be confirmed approximately ten(10)
<br /> days after e t of application, The files will be held for a maximum of five business days for review. Appoihtments
<br /> should be sc�e duled accordingly.
<br /> 3. A file that Is Hely being worked on by EHD staff may not be immediately available for review, A new applicatlon maybe
<br /> submitted w e i the file Is available,
<br /> 4. Arty file not r t med In the same condition as released will bE reorganized by EHD staff at the ex ense of the ee Ilett
<br /> Future file re1 ws by the same applicant may require a$125 deposit prior to revlew. - gOxE EA-` `-Y3E`—GNI try
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<br /> R e c e i v e d Time i pr. 15' 2014 1 : 16PM No, 5793
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