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DAT --I i V <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTNIIENIT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.org/ehd <br />3rT022016 <br />ENV.RIROf+I ENTAL HFALTN <br />ellt•Ru ne.-....__ <br />BLIC RECORDS RELEASE APPLICATION <br />EHD LOG NUMBER <br />,PPLICANT: I <`q C' . BUSINESS/AGENCY: <br />AddRESS:(q G I CETY/STATEIZIP: �eyti� <br />PHONE (1): Zd�� f — ',() I GdayPHONE (2): FAX 0P E MAIL: <br />Please allow 10 business s from date of application submittal for the records to be available. <br />Staff will contact u to arrange an appointment date and time to review the requested records. <br />❑ CHECK BOX TO EXPEDI R UEST - $139 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICAC7 <br />NT DATE 2 r f <br />1. List up to tei�, addresses n the p4ce b lover. Select the type(s) of files from the list below 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 viri;I 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 fire 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 appligant may require a $139 deposit prior to review. <br />WELL AMID SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:OOPM (EXCLUDIHIG HOLIDAYS) <br />EiectrOriic i'IEiorrnretro€i: r ie`i n rt ap - Description: <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Fea C ,re DDRES- <br />1, '1-. t� ttL s <br />FILES <br />Ems' <br />EF(D U -SE ONLY <br />UNDERGROUND TANK (UST) <br />Street # <br />Street Name <br />City <br />CLEANUP SITE (LOP) <br />L[:] CONSUMER <br />OTHER CLEANUP SITE (NON -LOP) <br />t �✓ <br />E — i y <br />HAZARDOUS WASTE <br />I I TIERED PERMITTED FACILITY <br />2 <br />�., A <br />I _ _ <br />I <br />E] DAIRY <br />II <br />