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i0 n, EHD LOG NUMBER <br /> t�IRRUC a `� SAV.TOAQUIN COUNTY <br /> APR .l M6 304 <br /> HEALTH DEPARTWI NT <br /> 304 East Weber Avenue,3rd Floor, Stockton, CA 95202-270800 <br /> ENVIP0�1NSE1J I')1EALfflephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 3 <br /> PERMIT/SEROCES PUBLIC RECORDS RELEASE APPLICATION <br /> �2 �/ <br /> APPLICANT:_�T l 11Ar' o ( TL,�d Qr BUSINESS/AGENCY: ) ca^6 .�I-V". <br /> v�p <br /> ADDRESS: p <br /> ..._'�� J� S. Ra�ljnv.oc-k. . 1*5oa Flt a_ I�„Jor+n;T C-� ,C)lID <br /> PHONE(1);_7 0 - �1 t1'�`cJ�g:J PHONE(2): FACSIMILE: 3a3 9--9�aS <br /> TENTATIVE'APAOINTNIIENT DATE: T r s de i {�p r. IS Time:_ <br /> (Please allow 10 business days from date of appllcatl�in submittal-•Tentative onty-mui.t be conflmwd) <br /> ®'CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OFAPPLICANT ( a �_ �8� _DATE <br /> UNIT DISTRIBUTION 12 unit ❑ Unit ❑ Unit A Unit4 0 Unit Q Unit M Other(alectrvniGibtshnaps) <br /> FILE ADDRESS EHD USE ONLY <br /> Srrsetk Street Name CItY <br /> 1. 39 g LN <br /> 99 <br /> 2, fv <br /> 3. <br /> 4. <br /> 10. <br /> Specific Date Range of Information Requested:From to _ <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> IWUNDERGROUIID TANK(UST)CLEANUP SITE(LOP) =HOUSINGAWATEMEtIT ❑SOCIO WAS TE FACILITYIVEHiCLE <br /> R OTHER CLEANUP SITE(RON-LOP) MFOOD FAGIuTY ❑WASETTRE <br /> Mr UNDERGROUND TANK(MOMTORINGIREMOVAL) M 000 KENNEL 1:3 DNRY <br /> MrHAZARDOM WASTE GENERATOR 0cfticnN RANCH ❑WASTEWATER TREAYmExT PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MOTEUHOML O PUMPER TTTUCKlYARDICHEM TOILETS <br /> 0 TATTOOIBODY PIERCING 0 POOUSPA ❑LAND USE APPLICATION SITES <br /> 13 MEDICAL WASTE FACILITY M OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVa1LABLE FOR REVIEW- MONDAY+FRIDAY 5:00 AMS: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 <br /> appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the address <br /> indicated above. Address ranges will not be accepted-for additional assistance with file addresses,contact <br /> the EHD.Applications received after 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 <br /> approximately ten(10) days after receipt of application. The flies will be held for a maximum of five business <br /> days for review. Appointments should be scheduled accordingly. <br /> 3. A file that is actively tieing worked on by EHD staff may not be Immediately available for review. A new <br /> application may be submitted when the file is available, <br /> 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the <br /> applicant. Future file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> 1 - <br /> ENO N.o2� <br /> inose <br /> E0/Z0 39tid 9NIll1161,100 E3 9ZL688LE0E LL:ET 90OZ/L000 <br />