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Ra 6Y ' .�A V E D EHD LV,G NUMBER <br /> SAN JOAQUIN COUNTY fn <br /> MAY 2 9 2014 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ENVIRONMENTAL HEALT�elephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: Pk/ID &'i BUSINESS/AGENCY: <br /> ADDRESS: /0� 6roc, - Qft CITY/STATE/ZIP: <br /> PHONE (1): 530 PHONE (2): �73o 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 REQU 125 FEE AS OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS C, <br /> SIGNATURE OF APPLICANT // %/,` � DATE <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City <br /> CI Unit 1 <br /> 1. 5 RM&6v LA Air Low <br /> 2. I I ❑Unit 2 <br /> 3. I a <br /> 4. <br /> 6. <br /> 7. <br /> 8. I Unit 5 <br /> 9. <br /> 10. I I t 4 �'ry nif o <br /> Specific Date Range of Information Requested: From to r <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> [UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY azSOLID WASTE FACILITYNEHICLE <br /> .OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT WASTE TIRE <br /> f�1791NDERGROUND TANK(MON ITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> FTHAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTEL/HOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ❑TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOOIBODY PIERCING �OMPLAINTIRESPONSE 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$125 deposit prior to review. —BOXED AREA-EHD USE ONLY— <br /> El Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 4846 4128114 <br />