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DATE RECEIV EHD LOG NUMBER <br /> D <br /> NV <br /> SAN JOAQUIN COUNTY <br /> NVED ENVIRONMENTAL HEALTH DEPARTMENT /� <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Q Thone: (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd ` 1 <br /> L EAL <br /> N PLIBLIC RECORDS RELEASE APPLICATION <br /> AP(3LIC9, T: 9hFFA- 1 /�1 BUSINESS/AGENCY:/�et- 1D/utt/lGtr yy25` —lffi e. <br /> ADDRESS: ��� l Opus AgeeC a SJI f� (VD CITY/STATE/ZIP:004),q0_S (?ore �L (OSIS <br /> PHONE (1): 30qS-- G (© PHONE(2): FACSIMILE:A_ JQ —115-6 <br /> TENTA IVE'APPOINTMENTDATE: ,�J�{{ Time: WA(Please allow 10 business days from date of ap lication submittal-'Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST- 25 FEE(CASH CH K ONLY)-REQUEST PROCESSED IN 3 BUST ESS D YS <br /> SIGNATURE OF APPLICANT �! DATE <br /> Electronic information: ❑ List❑ Map—Description: <br /> 1' FILE ADDRESS EHD USE ONLY <br /> D{(✓ Street# Street Name City ❑Unit 1 <br /> ��� 1• 'd70D7AivR hAl gmd1 , �1v1 <br /> 2. a Unit 2 <br /> 3.. ) / <br /> 4• Unit 3 1 <br /> 5. ,o <br /> 6. [1.11nit 4 <br /> T. <br /> 8• ❑Unit 5 <br /> 9. <br /> 10. ❑Unit 6 <br /> Specific Date Range of Information Requested: From to e4l <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FIA,CIUTYIVEHICLE ,/ <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT E]WASTE TIRE y C /Q/—tVl( �" <br /> UNDERGROUND TANK(MONITORING/REMOVAL' ❑FOOD FACILITY ❑DAIRY <br /> ABOVEGROUND TANKrye- ❑CHICKEN RANCHI DOG KENNEL WASTEWATERT2enT E <br /> HAZARDOUS WASTEIHAZARDOUS MATERIAL ❑MOTELIHOTEL PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> TIERED PERMITTED FACILITY `❑,POOLISPA LAND USE APPLICATION SITES <br /> ❑TATTOOIBODY PIERCING A COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(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-for additional assistance with file addresses,contact the EHD. Applications received after <br /> 3:00 pm will be processed the next business day. <br /> 2. 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 /> 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be <br /> submitted when the file is available. <br /> Y 9 Y - Papplicant.... <br /> 4. An file not returned in the same condition as released will be reorganized b EHD staff at the expense o the <br /> Future file reviews by the same applicant may require a$125 deposit prior to review. '""BOXED AREA-EHD USE ONLY <br /> (DA 0 <br /> t <br /> ❑ Records provided by Staff-PPR Complete.staff Name: <br /> EHD 48-06 9i4. <br />