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DAT /fit: SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �j 2016 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> Pi=17n,g1Tfa // <br /> EP�l1/IROf1TE,ER!q HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> nCr <br /> opo <br /> APPLICANT: `� �_� �� C��4 &- BUSINESS/AGENCY: <br /> ADDRESS: �� �(�, �J(-V�;�, s CITY/STATE/ZIP: $CC�LK i�tS 1cab <br /> PHONE (1): 6 p`7 4-p-, PHONE (2): a.0c-af q-3, ,�k 017CO FAX OR E-MAIL: Cr_l_n�/�L�l,cCtYtsT <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. CAn <br /> ❑ CHECK BOX TO EXPED E REQUEST-$139 EE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINE S DAYS <br /> SIGNATURE OF APPLICANT ,,tL DATE lb ( 3 (6 <br /> 1. List up to ten addresses in the spa6e below. Select the type(s)of files from the list below 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$139 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List ❑ Map- Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES EHD USE ONLY <br /> UNDERGROUND TANK(UST) Street# Street Name City <br /> CLEANUP SITE(LOP) E]CONSUMER <br /> OTHER CLEANUP SITE(NON-LOP) LV cAk(s,,, m S l_t _ ...t �'l Y/'1 PI 1� I�..0 <br /> "HAZARDOUS WASTE _ °A"CC VV Jl� l.0 I I I,rr 111 I I V (/(El <br /> ❑DAIRY <br /> dTIERED PERMITTED FACILITY <br /> IVIu ABOVEGROUND TANK <br /> I-1 UST (MONITORING/REMOVAL) ❑PWS <br /> HAZARDOUS MATERIALS 3 <br /> LI SPILL/RELEASE RESPONSE <br /> WATER QUALITY <br /> SOLID WASTE FACILITY/VEHICLE 4 <br /> WOOD FACILITY / 1 <br /> POOL/SPA SITE MITIGATION <br /> DAIRY 6 I <br /> LAND USE APPLICATION SITES <br /> ❑ <br /> SEPTIC PUMPER TRUCK/ 6 HOUSING <br /> YARD/CHEMICAL TOILETS <br /> ❑WASTEWATER TREATMENT PLANT 4CUPA <br /> ❑HOUSING ABATEMENT 7 <br /> F_�MOTEL/HOTEL <br /> CHICKEN RANCH/DOG KENNEL CUPA-UST <br /> 8 <br /> MEDICAL WASTE FACILITY <br /> TATTOO/BODY PIERCING <br /> SOLID WASTE <br /> WASTE TIRE g <br /> COMPLAINT <br /> OTHER(PLEASE SPECIFY): ❑ACCOUNTING <br /> 10 <br /> —BOXED AREA-EHD USE ONLY*** <br /> ❑ Records provided by Staff-PPR Complete. staff Name: <br /> EHD 48-06 , <br />