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t VL V SAN JOAQUIN COUNTY ��EHD LOG NUMBER <br /> ENVIRONMENTAL HEALTH DEPARTM N� <br /> SEP 2 2096 1868 East Hazelton Avenue, Stockton, CA 95205-623 V <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: - W610y " BUSINESS/AGENCY:F0?a_(3'L 61VIRIn u� wi} <br /> ADDRESS: 19pu W-01 Coti»in® AW CITY/STATE/ZIP: SG7olzcn'IP.YhOj Gq G(cg33 <br /> PHONE(i): Cvj )+f 1{- 1�5�f PHONE (2):�gg��µ}y- 'J�Ogi) ORE-MAIL: <br /> Ile. YCLh00•cO vl <br /> Please allow 113 business days from date of application submittal for the records to bb available-' <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$139 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> 1. List up to ten addresses in the space below. Select the type(s)of files from the list below b Checking the a <br /> box(es). At least one file Y g ppropri dr <br /> type MUST be selected. Fax to(2091 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) <br /> P.I OTHER CLEANUP SITE(NON-LOP) ❑CONSUMER <br /> T®HAZARDOUS WASTE <br /> TIERED PERMITTED FACILITY /I/ T ^ �n ❑DAIRY <br /> ®ABOVEGROUND TANK [/�rV(ly l7�/1 <br /> UST (MONITORING I REMOVAL) `/II PJ <br /> WS <br /> ffi HAZARDOUS MATERIALS <br /> SPILL/RELEASE RESPONSE <br /> ❑ <br /> SOILS WASTE FACILITY I VEHICLE 4 WATER OUALRY NU' <br /> ❑FOOD FACILITY n -2-M 1T' <br /> ❑ <br /> POOL/SPA (Bill SITE MITIGATION <br /> ❑DAIRY 6 <br /> ❑LAND USE APPLICATION SITES <br /> ❑SEPTIC PUMPER TRUCK/ 6 E HOUSING <br /> YARD/CHEMICAL TOILETS <br /> ❑WASTEWATER TREATMENT PLANT <br /> ❑HOUSING ABATEMENT 7 RI CUPA <br /> ❑MOTELIHOTEL <br /> ❑CHICKEN RANCH/DOG KENNEL CUPA-UST <br /> MEDICAL WASTE FACILFY 6 <br /> ❑TATTOOISODY PIERCING <br /> ❑WASTE TIRE 9 E SOLID WASTE <br /> ❑ <br /> COMPLAINT <br /> ❑OTHER(PLEASE SPECIFY): <br /> �D ❑ACGGpMING <br /> ""BOXED AREA-EHD USE ONLY••• <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 48-06 <br />