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REG` C! V�/ED • EHD LOG NUMBER <br /> vSAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> FEB 2 5 2015 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> e �.�rf�, Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERCES PUBLIC RECORDS RELEASE APPLICATION <br /> VI <br /> APPLICANT:`) R�� N1`7.0-k �jN C H BUSINESS/AGENCY: <br /> ADDRESS: _QGQ?6 l 'l �. j CITY/STATE/ZIP:_kk5AAV4e C A <br /> PHONE(1): J3O GR ? 30±?_PHONE (2): �34Z-' 6(I FACSIMILE: <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to arr Tge an appointment date and time to review the requested records. <br /> E] CHECK BOX TO EXPEDITE REQU S -$0EE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS <br /> SIGNATURE OF APPLICANT <br /> DATE__62 <br /> Electronic Information: ❑ List❑Ma -Description: 3 <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City Unit 1 <br /> 1. eN — N L ti�r- 5 twr. 0 <br /> 2. <br /> ❑Unit 2 <br /> 3. <br /> 4. R(unit 3 <br /> 5. 1 ^ � // <br /> 6. J 'JJA';Ple5 � I, W ® Unit4 <br /> 8. <br /> 8. <br /> ❑ unit s <br /> 9. 77) <br /> 10. <br /> ❑ Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ,�,,/` ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> Ll�IDERGROUND TANK(UST)CLEANUP SITE(LOP) E:1MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYIVEHICLE <br /> 'OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> WNDERGROUND TANK(MONITORING/REMOVAL) gfOODFACILITY El DAIRY ' <br /> E910OVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT i <br /> LJ n RDOUS WASTEIHAZARDOUS MATERIALS ❑MOTEUHOTEL ❑PUMPER TRUCK/YARD/CHEMICAL TOILETS ! <br /> EN-rIERED PERMITTED FACILITY ❑POOL/SPA <br /> ❑TATTOOIBODY PIERCING M-e ❑LAND USE APPLICATION SITES <br /> LUv �OMPLAINTIRESPONBE RECORDS ❑OTHER(PLEASE SPECIFY) i <br /> WELLAND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM (EXCLUDING HOLIDAYS) i <br /> 1. List uD 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)484.0138 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$125 deposit prior to review. **'BOXED AREA-END USE ONLY" <br /> rao ek w i I4te r UtV Cke(oVe2 L.,% v;, L . <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 4906 <br /> 4/28/14 <br />