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DATE RECEIVED EHD LOG NUMBER <br /> — SAN JOAQUIN COUNTY <br /> ' , EN\,.kONMENTAL HEALTH DEPARTMCNT <br /> �L 1868 East Hazelton Avenue, Stockton, CA. 95205-6232 <br /> NOV 2' 201,I Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> �-,WRONMIENTAL PUBLIC RECORDS RELEASE APPLICATION <br /> 0 IW a <br /> APPLICANT: fj'c .�'iis� �Gr1�^.C6 BUSINESS/AGENCY: 1/ S <br /> i <br /> ADDRESS: CITY/STATE/ZIP: -- �- ;SctiK�1,��( C? 0147ro <br /> PHONE (1): .-to- pyo- 31 PHONE (2): qoA FACSIMILE: <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 EE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE it- <br /> Electronic <br /> t-Electronic Information: ❑ List ❑ Ma'j L Description: <br /> FILE ADDRESS <br /> Street# Street Name City EHD USE ONLY <br /> Is I &t ;k 300 <br /> 2. t ' ' - ❑ Unit 1 <br /> 3. <br /> El Unit 2 <br /> 4. <br /> ❑ Unit 2H <br /> 5. <br /> 6. nit 3 <br /> 7. <br /> ❑ Unit 4 <br /> 8. <br /> ❑ SITE MITIGATION <br /> P. <br /> j <br /> 10. © nit 5 <br /> Specific Date Range of Information Requested: From to 4�2r����'f- <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY Q SOLID WASTE FACILITYIVEHICLE <br /> ❑1 OTHER CLEANUP SITE(NON-LOP) 1❑HOUSING ABATEMENT ❑WASTE TIRE <br /> I❑UNDERGROUND TANK(MONITORING/REMOVAL) i❑FOOD FACILITY ❑DAIRY <br /> I❑ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> fill HAZARDOUS WASTEIHAZARDOUS MATERIALS I MI MOTELIHOTEL ❑pl IMPER TRI ICKIYARDICHEMICA TOILETS <br /> I❑'TIERED PERMITTED FACILITY 0 POOLISPALAND USE APPLICATION SITES <br /> TATTOO/BODY PIERCING ' ' COMPLAINTIRESPONSE RECORDS AIOTHER(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 /> I <br /> Records provided by Staff-PPR Complete. Staff Name: 1, <br /> EHD 48-06 _ - 7/1/15 <br />