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'Tr7LE . 4DV I EHD LOG NUMBER <br /> SAN .10AQUIN COUNTY <br /> MAY 19 2011 NVIRONMENTAL HEALTH DEPARTME 10161 <br /> ��7i2 1068 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 90 <br /> Ii/1RONMEAI"f!al�i1' H PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: is 1�"__-9 rJ BUSINESS/AGENCY: <br /> ADDRESS: &,r 9 6, CITY/STATE/ZIP:���� G j� LAI, Z Z12 <br /> PHONE(1): a0 j— ( PHONE (2): FAX OR E-MAIL: ,?2 fZ_. 5,x'7 7 S O <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 RE UEST-$13p,FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT ,,t . DATE <br /> 1. List up to ten addresses in thepace be ow. 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 /> 5130 <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) Q oz, //,--/ <br /> �i' - .` ❑CONSUMER <br /> I� 1 Do111------ fff/ ///'''+++ / ,J., 1 <br /> OTHER CLEANUP SITE(NON-LOP) :A ) <br /> I y I HAZARDOUS WASTE - - - DAIRY <br /> r <br /> '®TIERED PERMITTED FACILITY 2 0 <br /> ABOVEGROUND TANK <br /> UST (MONITORING/REMOVAL) PWS <br /> I <br /> �-I HAZARDOUS MATERIALS3A .r / S <br /> IX I SPILURELEASE RESPONSE I f <br /> r" WATER QUALITY <br /> n SOLID WASTE FACILITY/VEHICLE 4 �� 11v <br /> r]FOOD FACILITY V <br /> i <br /> POOL/SPA O SITE MITIGATION <br /> III--❑DAIRY 6 <br /> Iq I LAND USE APPLICATION SITES <br /> SEPTIC PUMPER TRUCK/ ❑HOUSING <br /> 6 <br /> YARD/CHEMICAL TOILETS <br /> WASTEWATER TREATMENT PLANT CUPA <br /> F]HOUSING ABATEMENT 7 <br /> 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 S <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 />