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RECEIVED <br /> SAN ,JOAQUIN Environmental Health Department <br /> --COU NTY--- PUBLIC RECORDS RELEASE APPLICATION <br /> r..nc;S „rnr h;9`1VIRONMLN.TALHEALM XW6 <br /> 751 <br /> PErWIT/SERVECE9 rz-f <br /> • EHD LOG NUMBER: /; <br /> APPLICANT: T&J (7` '0UA �i 1l BUSINESSIAGENCY:Vlff)rlPaI F'5-rd t? J� nQ vu 5P. <br /> ADDRESS: jr ! iS 614405 (j%j, 70- — CITY/STATE/ZIP: _ CR C(�J03 2 <br /> PHONE (1): gn17' -'dL%—()a PHONE(2): FAX OR E-MAIL: <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact yQfrto arran e a appointm date and time to review the requested records. <br /> SIGNATURE OF APPLICANT 1 � ) r ,71 DATE I —�j�-- ,"Z, ( 7 <br /> 1. List up to ten addresses in N ace below. Address ranges WILL NOT be accepted. Select the types)of flies from the <br /> list below by checking the appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138,mail to the <br /> address indicated below,or email to InfoGDsicehd.com. Applications received after 3:00 pm will be processed the next <br /> business day. <br /> 2. For assistance in Identifying the nature and content of EHD records,please contact EHD at the number noted below. <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$152 deposit prior to review. f <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> Electronic information: ❑List❑ Map—Description: <br /> Specific Date Range of Information Requested: From (` jr) to P.re5e <br /> ENVIRONMENTAL ( FILE ADDRESS <br /> HEALTH DEPARTMENT ponly, e p EHD USE ONLY <br /> FILES (Specific addresses address ranges will not be accepted) <br /> Underground Tank(UST) Street# Street Name City <br /> Cleanup Site(LOP) / .{- ^ t �s�t ❑coo WAee <br /> Other Cleanup Site(Non-LOP t �� Vv r $5f fh 6 t t 'qve' olty)�Q�'l <br /> • Hazardous Waste ❑DAIRY <br /> Q Tiered Permitted Facility 7j 2 1 �, [2ivlt�t, Avt' lU .d.+f z, ,r7 <br /> Aboveground Tank r J ` / tl`CY�ewK <br /> UST (Monitoring/Removal) C]PWS <br /> 3 <br /> Hazardous Malenals <br /> Spill I Release Response Brea DunuTY <br /> Solid Waste Faclity I Vehicle 4 <br /> ❑Food Facility <br /> ❑Pod I Spa <br /> Dairy SV1tALl/1 14�I/� 1 <br /> ❑Land Use Application Sites Hcusiac <br /> E]Septic Pumper Truck I e <br /> Yield I Chemical Toilets <br /> E]Wastewater Treatment Plant UPA <br /> M Housing Abatement T AST/HMIHW <br /> Motel/Hotel CUPA <br /> Chicken Ranch/Dog Kennel <br /> 6 UST <br /> Medical Waste Facility <br /> Talloo/Body Piercing ❑Seuo W.s <br /> Waste Tire g <br /> Complaint <br /> ❑Other(Please Specify): [3ACCOUNTING <br /> 1a <br /> —BOXED AREA-EHD USE ONLY"' <br /> ^Ln , e� r fi/nci C� s �( ^F;Ia r- � <br /> • so", _ <br /> ❑ Records provided by Staff-PPR om lete. staff Name: EHo 4e.a6 <br /> 1868 E. Hazelton Avenue ( Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0 38 1 www.sjcehd.coln <br />