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'06/2015 1 : 19 : 07 PM –0400 FAXCOM ANYWHERE PAGE 2 OF 2 <br /> • • <br /> GATE RECEIVEDJ� j� EHD LOG NUMBER <br /> / / SAN JOAQUIN COUNTY <br /> R(o ENVIRONMENTAL HEALTH DEPARTMENT <br /> (� JJ1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web:wwwsjgov.orglehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: &r. / ` w,z BUSINESS/AGENCY: <br /> ADDRESS: 3 �.11L11A _RI s� cLrZ— CITY/STATEIZIP: (�Q4 �_11g, GAgp <br /> PHONE(1): (qI4.9 �lS.3��--I PHONE(2):__�L'N,���1„6�� FACSIMILE: 7�_..e�_LL_L1.,. <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 F E(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BU INESS DAYS <br /> SIGNATURE OF APPLICANT DATE S <br /> Electronic Information: ❑ List ff Map–Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name city _ ❑Unit f <br /> —T. <br /> 2 8D I r�t� w As1—V'hL10 0nh2 <br /> 3 <br /> 4. 1 1 ��ll �,/fl�uueH3 <br /> 6.S. nr"aek Lt MICS VJ 0 O Unit 4 <br /> 7.._.. <br /> 8. El <br /> 9. <br /> 10. p LInit e <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> JUNDERGROUNo TANK(UST)CLEANUP SITE(LOP) MEDICAL WASTE FACILITY aSQLID WASTE FACILITYIVEHICLE <br /> HER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT WASTE TIRE <br /> DERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> OVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ZARDOUS WASTEMAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCK/YARD/CHEMICAL TOILETS <br /> RED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOOIBODY PIERCING ❑COMPLAINTIRESPONSE 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(2091464-0138 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 END records,please contact END 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 /> rt7v4rk �7 "r a (or LII16D A'A 'm N ITC - ok CJ) , - <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 4"6 - Oe/01114 <br /> Received Time May. 6. 2015 10: 19AM No, 8638 <br />