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DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd tDo <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: l/ j BUSINESS/AGENCY: E <br /> ADDRESS: �� ��CIAA 111` CITYISTATE/ZIP: ; - <br /> PHONE(1): s'- ( - j U 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 a oint ent date and time to review the requested records. <br /> ❑CHECK BOX TO EXPEDITE REQUEST 3 CA OR CHECK,-ONLY)) ST PROCESSED IN 3 BUSINE S DAYS <br /> SIGNATURE OF APPLICANT -^ DATE <br /> Electronic Information: ❑ List❑LMap—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑Unit 1 <br /> j2. NiPk N DIP ,t. lJl1`_ ❑Unit 2 <br /> V { <br /> 3. rf . A, �. � <br /> 4. <br /> ,Q Unit 3 <br /> 5. <br /> s• L L ❑Unit 4 <br /> 7. 1'�v`v'�t� P&,&A <br /> 8. 1Li) <br /> Q unit 5 <br /> 9. <br /> 10. 4VjA ❑Unit6 <br /> Specific Date Range of Information Requested: From ( to /�+ <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> DERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYNEHICLE <br /> ,��ER CLEANUP SITE(NON-LOP) El HOUSING ABATEMENT ❑WASTE TIRE <br /> Ltd L}MDERGROUND TANK(MONITORING/REMOVAL) ❑FOOD FACILITY ElDAIRY <br /> ��WRD <br /> GROUND TANK E]CHICKEN RANCH/DOG KENNEL E]WASTEWATER TREATMENT PLANT <br /> OUSWASTE/HAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEM[CAL TOILETS <br /> TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOO/BODY PIERCING ❑COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(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 /> ee_ I OYlGz 4,0 -fes C+4e/' in W,_( j1kc 6.r ���, 1�`��, (OC)(_7 S'A <br /> ❑ Records provided by Staff-PPR Complete.Staff Name: <br /> EHD 48-06 08101/14 <br />