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IN <br />CEEI� <br />`JE SAN JOA,QUIN COUNTY EHD LOG NUMBER <br />ENVIRON110ENTAL HEALTH DEPARTMENT <br />AR 3 0 2016 1868 East Hazelton Avenue, Stockton, CA 95205-6232 l <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.org/ehd <br />PERMIF1SEM'tCF—:8 PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: '`hNV)1fTLO/`y BUSINESS/AGENCY: <br />'n <br />ADDRESS. L S����yy�� �`Y11ti 1� � o\AA 0 C� I�IITY/STATE/ZIP: GL\J1_ <br />�r <br />PHONE (1): C�Z� 1 'T `(1 ''*p C �C) PHONE (2): FACSIMILE: i 01 Z S1 4�r - I (C �l�'? <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 REQUEST - $130 FEE (CASH OCHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT j63,2 G? \A Ct 4, `- Ri l e: �,�� DATE " /Lcl II I u <br />Electronic Information: ❑ List ❑ Map - Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />Street # <br />Street Name <br />City <br />�- <br />C Unit 1 <br />2.Z <br />S <br />[A414 7 <br />�' <br />3. <br />['Unit 2 <br />4. <br />19/unit 2H <br />5. <br />2-dan',it <br />I�/ 3 <br />6. <br />7. <br />❑ Unit 4 <br />8. <br />SITE MITIGATION <br />[9. <br />ED/Unit 5 <br />10. <br />Specific Date Range of Information Requested: From l� LI— to <br />EN ilIRONNIIENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) © MEDICAL WASTE FACILITY © SOLID WASTE FACILITYNEHICLE <br />OTHER CLEANUP SITE (NON -LOP) HOUSING ABATEMENT WASTE TIRE <br />UNDERGROUND TANK (MONITORING/REMOVAL) FOOD FACILITY DAIRY <br />ABOVEGROUND TANK CHICKEN RANCH/ DOG KENNEL WASTEWATER TREATMENT PLANT <br />HAZARDOUS WASTEIHAZARDOUS MATERIALS ® MOTELIHOTEL PUMPER TRUCK/YARD/CHEMICAL TOILETS <br />TIERED PERMITTED FACILITY [ POOL/SPA LAND USE APPLICATION SITES <br />TATTOOIBODY PIERCING ® COMPLAINT/RESPONSE 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 $130 deposit prior to review. ***BOXED AREA -EHD USE ONLY*** <br />❑ Records provided by Staff -PPR Complete. staff Name: LJ (f <br />EHD 4"6 711H5 <br />