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RECEIVED <br />DATE RECEIVED us f4r, <br />D LOG NUMBER <br />APP 14 201, ��t�lE���� Y . <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />EWEF/iENT 1868 East Hazelton avenue, Stockton, CA 95205-6232 �4 <br />PfFiTfSEICpEZotTe: (209) 468-3420 Fax: (209) 464-013$eE�:vnrv.sjgov.org/ehd <br />rVA <br />emt- <br />pPUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: l�A u I p $7C%[,t% BUSINESS/AGENCY: (—,6 t r r��(Uc' i •1 � � <br />ADDRESS: �� �'j� (liA)A)I"1 � CITY/STATE/ZIP: <br />PHONE (1):rj t t//��C%_> PHONE (2): -' FAX OR E-MAIL: r o v� ! iJr,,t <br />Please alloy 10 business days from date of application submittal for the records to he 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 OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT <br />DATE <br />Electronic Information: ❑ List ❑ Flap — Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />Street t/ <br />Street fame <br />City <br />1. <br />tt <br />f �oo <br />PA5r INI 1,� <br />] <br />bwflxu- <br />❑ Unit t <br />2. <br />3. <br />[2'/Unit 2 <br />❑ Unit 2H <br />5. <br />(Sl' nit 3 <br />6.� <br />t �� .I Y / <br />) Unit 3Hf1 <br />7. <br />❑ Unit 4 <br />i3. <br />i9/SITE MITIGATION <br />S. <br />❑ Unit 5 <br />10. <br />apecmc uace Kange or intonnation requested: From to <br />ENV] n I e` I IES <br />� R IVs Et.T,�... HEALTH DEPri%4TivlEie'e r'if.tS <br />NDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MOTELIHOTEL ❑ SOLID WASTE FACILITYNEHICLE <br />THER CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT ❑ FOOD FACILITY <br />NDERGROUND TANK (MONITORINGIREMOVAL) ❑ WASTE TIRE ❑ DAIRY, POOUSPA <br />BOVEGROUND TANK ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER TREATMENT PLANT <br />-AZARDOUS WASTE ❑ MEDICAL WASTE FACILITY ❑ PUMPER TRUCK/YARDICHEWCAL TOILETS <br />AZARDOUS MATERIALS ❑ TATTOOIBODY PIERCING ❑ LAND USE APPLICATION SITES <br />TIERED PERMITTED FACILITY 12.901?.PLAINT/RESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: /MONDAY -FRIDAY 8:00 Ate-5:00PM (ExCLUDI,''G FOLIDMYS) <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 />shouid 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 />—BOXED AREA - EHD USE ONLY` <br />Lv1 C <br />0 Records provided by Staff -PPR Cont fete. Staff Name: n G <br />