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Ci/ ADDRESS: p 6 X <br />PHONE(14 1(4) 14), PHONE (2): <br />TENTATt E* APPOINTMENT DATE: <br />DATE RECEIVED <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />An_ 31 2TAfp phone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />RECORDS RELEASE APPLICATION <br />APPLICANT: -T-(1 (J.-1:;•CY- BUSINESS/AGENCY: CAA_ fV(. PP <br />CITY/STATE/ZIP: <br />'rI <br />FACSIMILE: <br />Time: <br />EHD LOG NUMBER <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />laMEDICAL WASTE FACILITY <br />0 HOUSING ABATEMENT <br />LI FOOD FACILITY <br />0 CHICKEN RANCH/ DOG KENNEL <br />0 MOTEL/HOTEL <br />LIJPOOLISPA <br />COMPLAINT/RESPONSE RECORDS <br /> to <br />ESOLID WASTE FACILITY/VEHICLE <br />El WASTE TIRE <br />0 DAIRY <br />IDWASTEWATER TREATMENT PLANT <br />0 PUMPER TRUCK/YARDICHEMICAL TOILETS <br />0LAND USE APPLICATION SITES <br />0 OTHER (PLEASE SPECIFY) <br />Specific Date Range of Information Requested: From <br />0-UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />MOTHER CLEANUP SITE (NON-LOP) <br />J UNDERGROUND TANK (MONITORING/REMOVAL) <br />ABOVEGROUND TANK <br />HAZARDOUS WASTE/HAZARDOUS MATERIALS <br />Di TIERED PERMITTED FACILITY <br />OTATTOOIBODY PIERCING <br />(Please allow 10 business <br />0 CHECK BOX TO EXPEDITE REQUE <br />SIGNATURE OF APPLICANT <br />ys from date of application submittal - *Tentative only - must be confirmed) <br />-$1 <br />FEE CASH HECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> DATE r1I 13 <br />I Electronic Information: fl List LI Map —11Description: <br />t , <br />I <br />FILE ADDRESS EHD USE ONLY <br />, / <br />L-l'Unit 1 <br />_ Street # Street Name City <br />1,1. • . - t. ' -Zr? <br />T.L.,\...:U0 ?;y) g t p2(.----'cvv----, ?Unit a 2 <br />4- <br />I-Unit 3 69 (4 (7011 L o x 't1C- g-- A ___ 51-C-Cidt7P <br /> <br />Cf‘-'1") CV/43 Aljnit4 jil (., 6 A( 0- I c if <br /> ,Q3 go ri t‘ 266-D "- t( <br />,--4- fp Unit 5 - Z 5 9 ri ... 1.,. .._. t( <br />9- c; 350 f\ tt_ I ( t ( <br />Erflnit 6 <br />(t) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 Ann-5:00Pm (EXCLUDING HOLIDAYS) <br />I. 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 />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 he held for a maximum of five business days for review. Appointments <br />should he scheduled accordingly. <br />A file that is actively being worked on by END staff may not be immediately available for review. A new application may be <br />submitted when the file is available. <br />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 />--k.-e d—c:: tv...7-f—Lcz-ei, 14.7.714,1— A4i 9 /7 -leki Q _; tu _ <br />, A C I . C710 L-• 21? q 141(1,41i ' • rt51 /..% ..-2. I 211? , ,.....11.. 14,-; 4 • ,-, i. ,., -"2.--a-z` tscjr, 1 .2 . - , - - .., <br />, ,,f <br />A Pr/ 1,1----1, ; - 0,4),A .: 1-firiy...,,_,J. /.1 0 ,1;7. _ ,i, .,-.....-1.-7.-) f.Q.Acin"../1-4., _ , <br />k.., <br />(4 <br />/ <br />( K (:)/...-!-. e /4 <br />Records provided by Staff-PPR Complete. Staff Name: <br />EHD 48-06