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InHrc I LUUO L 91PM MOUN EARTH TECH <br /> �y11L�� �Jf N0. 5926 P. 2 <br /> i ^ Lt1JenE� 1 <br /> SAN.TOAQUIN COUNTY EHD LOG NUMBER <br /> MA EINWMONMNTAL HEALTH DE,PARTMENT <br /> ENVP0f,1!,'IEm HEALTH 304 East Weber Avenue, 3r1 F100r, Stockton,CA 95202-2708 *7 <br /> PERpfl1;JEplvICEJ Telephone: (209)468-3420 Fax:(209)464.0138 Web:wwwsjgov.org/ehd <br /> (7n PUBL C RECORDS RELEASE APPLICATION <br /> APPLICANT: Q� &R t4 S' SIN /AGENCY: <br /> ADDRESS: ( VV <br /> PHONE(1): PHONE(2): 9-2 <br /> FACSIMILE: C Y� <br /> TENTATIVE*APPOINTMENT DATE' .12 O(p 1 '.gvoln <br /> (Please allow 10 business days from d o 'cation submittal-'Twtauvo only-must be c nflmsd) <br /> d CHECK BOX TO EXPEDITE RE T.$93.0 FEE( CHECK ONLY)- <br /> REQUEST PROCESSED IN j 91.1 /NESS DAYS <br /> SIGNATURE OF APPLIC T I DATE 0� <br /> UNIT b15TJBUTION ❑Unit? Cl Unit2 ❑Unit UnR4 ❑Unh5 C3 Units 0 Other(elecbonidlists/maps) <br /> FELE ADDRESS <br /> SDcct tt Street Name , EHD USE ONLY <br /> 2. b l AS Y AA( it <br /> t Tj u <br /> 3, p rj <br /> 4. <br /> i <br /> 7. c✓!C6 p' S 1 �'�j <br /> 7. '70 <br /> o k�Ytc <br /> 8• "h A" ✓ <br /> p Ynotz.�. <br /> 10. I 20 <br /> Specific Date Range of Information Requested:From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNOERGRGUND TANK(UST)CLEANUP SrMfLOP) ❑HOUSING ABATEMENT <br /> OTHERCLEANUP SITE SpuD WASTE FACILrtrNENICLE <br /> Non-LOP <br /> ( ) ❑FOOD FACILITY O WASTE TRE <br /> NOERGROUNGTANK(MONITOiUNGIREKOVg ) ❑DOG KENNEL <br /> HAZARDOUS WASTE GENERATOR TaCl DAIRY <br /> TIERED PERNnTFD FACILnY CHICKEN RANCH WASTE <br /> WATER TRATMENT PLANTU MOTELIH <br /> TATTOO/BODY PIERCING {PUMPER TRUCYJYgRClCHEM TOILETS <br /> MEDICAL WASTE FALaUTf 13 13 OTHERPOOL/ PA(PLEASE SPECIFY) JV LAND USE APPLICATION SITES <br /> TNER <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW- M1tONDAY-FRIpgY B:DD AkS:OepM - EXCLUO[NG HOLIDAYS. <br /> 1. List Up to ten addresses in the space above. Select the type($)of files from the list above by checking the <br /> appropriate bOX(e$). At least one file type MUST be selected. Fax to(209)404-0138 or mail to the address <br /> Indicated above. Address ranges Will not be accepted—for additional assistance with file addresses, contact <br /> the EHD.Applications received after 3:00 pm will be processed the next business day. <br /> 2, The EHD will notify the applicant if any EHD flies exist An appointment for review will be confirmed <br /> approximately ten(10)days after receipt of application. The files will be held for a maximum of five business <br /> days for review. Appointments should be scheduled accordingly. <br /> 3. A file that is actively being worked on by EHD staff may not be immediately available for review, A new <br /> application may be submitted when the file is available. <br /> 4. Any file not retumed In the same condition as released will be reorganized by END staff at the expense of the <br /> applicant Future file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> " I� v <br /> END i 2&6 <br /> Maros <br />