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RECEIVED <br />DATE RECEIVED SAN JOAQUIN COUNTY EHD LOG NUMBER <br />JAN i G 2012 ENVIRONMENTAL HEALTH DEPARTMENT <br />I F 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />elephone: (209) 468-3420 Fax: (209) 464-0138 Web: www,sjgov.org/ehd <br />015*�592— <br />PEFWrrrSEFVVMPUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT <br />ADDRESS: <br />_BUSINESS/AGENCY; <br />CITY/STATE/ZIP: <br />PHONE (1): C-43 - 1- 3 PHONE (2): FAX OR E-MAIL:. &miZ K J& pu Is)__ <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 />CK BOX TO EXPEDITE REQUEST - $139 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIG OF APPLICANT DATE <br />I List uo to ten addresses in the space below. 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 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 $139 deposit prior to review. <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM•5:OOPM (EXCLUDING HOLIDAYS) <br />Electronic Information: ❑ List ❑ Map - Description: <br />Specific Date Range of Information Requested: From to <br />)e <br />-Vowt - <br />zo-17 <br />s <br />ENVIRONMENTAL <br />mat <br />HEALTH DEPARTMENT <br />FILE ADDRESS <br />EHD USE ONLY l� <br />FILES <br />UNDERGROUND TANK (UST) sV <br />Street # <br />Street Name <br />City <br />'] <br />g /S <br />i <br />�� f�i <br />�,g <br />® i � z / <br />J'® <br />,' "'"'" 'v' ❑ CONSUMER <br />I ,B� <br />t/' 8 / P <br />CLEANUP SITE (LOP) <br />OTHER CLEANUP SITE (NON -L <br />HAZARDOUS WASTE <br />TIERED PERMITTED FACILITY <br />11�((% <br />®t„ )Ir. , <br />an- ❑ DAIRY <br />QABOVEGROUND TANK <br />17 <br />) j1 _ _ <br />❑ PWS <br />BUST (MONITORING / REMOVAL) <br />isl HAZARDOUS MATERIALS <br />/V <br />N SPILURELEASE RESPONSE <br />0 SOLID WASTE FACILITY / VE <br />I {/B <br />/ / , �I/ 1 i <br />�'i.V"`^ <br />WATER QUALITY <br />FOOD FACILITY <br />POOL I SPA�'''��yy�� <br />DAIRY <br />P10 <br />/d{� `dy-/r'/G�� <br />5. / .��( Y f W "' y <br />✓I G %/ 1_� <br />(7/ t'� 1 ®/'� <br />l{��(R L i , ITEM 11 ON <br />' i E � F 1 {y� ✓,ss <br />LAND USE APPLICATION SITES <br />./f� <br />s <br />«�® <br />PC°/r" <br />D <br />1'6C li,4 <br />, s, <br />❑ HOUSING <br />SEPTIC PUMPER TRUCK / <br />YARD /CHEMICAL TOILETS <br />E] WASTEWATER TREATMENT PUNT <br />F1 HOUSING ABATEMENT <br />ii ®1 � � <br />7 <br />t/�'Jl <br />�, <br />_ <br />rf / � // <br />5 <br />14 <br />41 <br />CUPA <br />F1 MOTEL/HOTEL <br />/! <br />• Jr V{0 <br />06 <br />i -I CHICKEN RANCH / DOG KENNEL <br />E] MEDICAL WASTE FACILITY <br />\\ <br />1 <br />j <br />G jr- (Vy, <br />n r/•� <br />_ CUPA - UST <br />t rP C <br />TATTOO/BODY PIERCING <br />WASTE TIRE <br />,`{ <br />""" `� <br />B <br />Gk� <br />.,� ❑ Som WASTE <br />COMPLAINT <br />OTHER(PLEASE SPECIFY): <br />r <br />Qb <br />BOXED AREA - EHD USE ONLY— <br />W, <br />NLY- <br />- <br />Sp <br />�1I''-VIA <br />li.� <br />EHD 48-06 CO <br />rI'! C�'C Rgg--$j I/ 1E1�/r�t 1 /i/��/�'9�(y✓' <br />7 5l .�j ( .r,'t; I "LA r1T `0- 4� s% V `7,� l✓ ®� i `d Il i % <7(�()i> f'1� a <br />