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ID C IVE EHD LOG NUMBER <br /> D�q SAN .10AQUIN COUNTY <br /> OCT 2 6. 2016 ENVIRONMENTAL HEALTH DEPARTMENT AGM �?C;\(e�A�.UDM <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> EWROWEXTAI-htM"hone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> P'ERUATMF.3 .& . <br /> PUBLIC RECORDS RELEASE APPLICATION 89 q I Z <br /> APPLICANT: l voty-5 BUSINESS/AGENCY: ok �%06k h--� SNL• <br /> ADDRESS: D S (L S V� 3ZCITY/STATE/ZIP:' OlO " 1U� , GA 15u(p <br /> PHONE(1): �`V PHONE(2}: FAX OR E-MAIL: C( Va\2 )0'fUU,OIAitOt,�U�15 <br /> Please al ow 10 business days from date of application submittal for the records to be available. •90y" <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑CHECK BOX TO EXPEDITE T-$13 H HECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: ❑ List Map–Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name C�tY <br /> Ci4eM C <br /> W��I�I)/l It V r � Unit 2 <br /> OD 4 {^1 L^tel El Unit 2H <br /> 5. nit 3 <br /> s. PIP <br /> 7 ❑Unit 4 <br /> 8 SITE MITIGATION <br /> 9. 5dunit 5 <br /> 10. <br /> Specific Date Range of Information Requested: From ALL to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES ���yyy <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) E]MOTELIHOTEL J�SOLID WASTE FAC(LfrYIVEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) El HOUSING ABATEMENT amu}FOOD FACILITY <br /> 9UNDERGROUND TANK(MONITORING/REMOVAL) ❑WASTE TIRE ❑DAIRY,POOUSPA <br /> ,ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTE ❑MEDICAL WASTE FACILITY E]PUMPER TRUCK/YARDICHEMICAL TOILETS <br /> HAZARDOUS MATERIALS ❑TATTOO/BODY PIERCING ❑LAND USE APPLICATION SITES <br /> 1£RED PERMITTED FACILITY ❑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. <br /> "*BOXED AREA-EHD USE ONLY— <br /> 00 L 3-7 -1W <br /> Co D I q-J <br /> 0 Records provided by Staff-PPR Complete, Staff Name: <br />