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P C 1V <br />�w••�+ EHD LOG NUMBER <br />RD� SAN .10AQUIN COUNTY <br />OCT 2 6 2016 ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />EWROW.E.WTAL Rft"hone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />i"E.F3WMERVi.Lc& - <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: MKL' 990LV-5 BUSINESS/AGENCY: ok �q-'0 k i'C_� )Nb - <br />ADDRESS: VhM S k S D V� 32-CITYISTATE/ZIP: '�DSfNl\.1I� , CA 150 <br />PHONE (1): 1W\1 <br />PHONE (2): FAX OR E-MAIL: Y(. �( \(? �O�VIL(O�QIS�O*I& <br />Pleasbusiness days from date of application submittal for the records to be available. • t,�YV1 <br />Staff will contact you to arrange an appointment date and time to review the requested records. <br />❑ CHECK BOX TO EXPEDITE /J ST- $13PEE„( H HECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />ctnwAT11CC nF APPI irAP ..F� /lY ]/L.1/1 [.�1 C/ DATE j�125� �i� <br />Electronic Information: <br />❑ List Map — Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />Street # <br />Street Name <br />City <br />7A-;2 Unit Z <br />❑Unit 2H <br />nit 3 <br />n� <br />{� <br />4 <br />7 <br />❑ Unit 4 <br />$ <br />SITE MITIGATION <br />9• <br />R Unit 5 <br />10. <br />Specific Date Range of Information Requested: From r v - <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MOTELIHOTEL SOLID WASTE FACILITYIVEHICLE <br />OTHER CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT FOOD FACILITY <br />9 UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ WASTE TIRE ❑ DAIRY, POOLISPA <br />ABOVEGROUND TANK ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER TREATMENT PLANT <br />[HAZARDOUS <br />AZARDOUS WASTE ❑ MEDICAL WASTE FACILITY F] PUMPER TRUCK/YARD/CHEMICAL TOILETS <br />MATERIALS ❑ TATTOOIBODY PIERCING ❑ LAND USE APPLICATION SITES <br />IERED PERMITTED FACILITY ❑ COMPLAINT/RESPONSE 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. 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. <br />"*anxFn AREA - FHD USE ONLY" <br />, 2 <br />00L7l�- c �1 <br />0 bou <br />i <br />❑ Records provided by Staff -PPR Complete. staff Name: <br />1 <br />I ►/3 <br />