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DATE RECEIVED EHD LOG NUMBER <br /> SAN .10AQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 too <br /> Telepho e: (209) 468-3420 Fax: (209) 464-0138 Web:www.sjgov.org/ehd <br /> UBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: 11 L1 BUSINESS/AGENCY: !- <br /> ADDRESS: �v' PIVv_ CITY/STATE/ZIP: n ad, <br /> PHONE(1): .0 PHONE (2): FACSIMILE: <br /> Please allow 10 b siness days from date of application submittal for the records to be available. <br /> Staff will contact ou to arrange an appoint ent date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPE ITE REQUEST 3 CA ICOR CHEC,I-:ONLY)_z_�EST PROCESSED IN 3 BUS INESS DAYS <br /> SIGNATURE OF APPLIC NT `' �<<-` DATE <br /> Electronic Information: List❑Map-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name I city ❑Unit 1 <br /> 1. ' z 100d"4A I) <br /> t1i�=t= <br /> j� 2. N? ` ( �.� a ,t A11-1' — T ❑Unit <br /> 3. E V <br /> 4. <br /> X]Unit 3 <br /> 5. <br /> 6• ❑Unit 4 <br /> 7• ani <br /> 8. ❑Unit 5 <br /> 9. ,,,� <br /> 10. r -1 ❑ Unit <br /> Specific Date Range of Information)Requested: From a ( I v> to S 105 <br /> ENVIRONMENTAL HEALTH • EPARTMENT FILES <br /> 6gPHER <br /> ERGROUND TANK(UST)CLEAN�IP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYIVEHICLE <br /> CLEANUP SITE(NON-LOP) ll ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> NDERGROUND TANK(MONITORING REMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> =DOUS <br /> GROUND TANK ❑CHICKEN RANCH/DOG KENNEL E]WASTEWATER TREATMENT PLANT <br /> WASTEIHAZARDOUSM TERIALS F1MOTELIHOTEL L]PUMPER TRUCK[YARDICHEMICALTOILETS <br /> ]TIERED PERMITTED FACILITY E]POOLISPA ❑LAND USE APPLICATION SITES <br /> F1TATTOOIBODY PIERCING ❑COMPLAINTIRESPONSE RECORDS El OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT R:RDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List up to ten addresses in a space above. Select the type(s)of files from the list above by checking the appropriate <br /> box(es). At least one file ty e 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 sa a applicant may require a$130 deposit prior to review. "`BOXED AREA-EHD USE ONLY* <br /> zz li z �o {e- cf t��' i^ t,�h •il Uf C.OUL�ZS�(Jti. <br /> ❑ Records provided by St ff-PPR Complete.Staff Name: <br /> EHD 4M6 08/01/14 <br />