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RECE VED <br /> DATE RECEIVED • SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> DEC. 3 0 2014 ENVIRONMENTAL HEALTH DEPARTMENT Vk\ <br /> ENVIRONMENTAL HEALW 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> PERMIT/SERVICES lephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> '16 15 <br /> PUBLIC RECOIRPS R LEASE APPLICATION �p/l <br /> APPLICANT: ` ,, I SINESS/AGENCY: (1 <br /> ADDRESS: W 7 ( CITYISTA E/ZIP: / C / / / <br /> PHONE(1).. �� PHONE(2): _ FACSIMILE: ZP1 - 33q—t/(-d' y <br /> Pldase allow 1U busiless day§from date of application submittal for the records to be available. <br /> Staff will contact you to arrange Ian agp Etmen date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$1 AS CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT /� DATE <br /> Electronic Information: ❑ List❑ Map-Description: <br /> FILE ADDRESS EHD USE LY <br /> Street# Street Name city M <br /> • El U .t' r ,. <br /> 1 3 ire/ z <br /> 3. b 3 L C� W a N I 1r ND c0(y <br /> � 77 ! /� tv E2 C�c� C1JOU�13`3�S /yl (.Q/K/l L-- nit 3 <br /> 6. t0 J <br /> ' '1 ,, _�- /Q I Nod m nit <br /> O POA ''MIA�n Ii IM-PI � r (.f'I ❑ Unit <br /> 9. rlY'S ds 4hl,'�. . <br /> 110. 1 71/7 <br /> ❑ Unit <br /> Specific Date Range of Information Requested: From ALTH DEP <br /> I to <br /> ENVIRONMENT L HEARTMENT FILES <br /> Af <br /> NDERGROUND TANK(UST)CLEANUP SITE(LOP) F]MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYIVEHICLE <br /> THER CLEANUP SITE(NON.LOP) F1 HOUSING ABATEMENT ❑WASTETIRE - <br /> NDERGROUND TANK(MONITORINGIREMOVAL) F1 FOOD FACILITY ❑ <br /> DAIRY <br /> I2VABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ,7HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARD/CHEMICAL TOILETS <br /> ❑TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> �7Y/ /,,� <br /> ElTATTOOIBODY PIERCING �OMPLAINT/RESPONSE RECORDS OTHE^'"'LEASE SPECIFY) OyP 41 <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 800 AM-5:OOPM(EXCLUDING HOLIDAY �4 /%� <br /> 1. List uD to ten addresses in the space above. Select the type(s)of flies from the list above by checking the appropriate y- .1,1 �., <br /> box(es). At least one file type MUST be selected. Fax to(209)464.0138 or mail to the address indicated above. Addres <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$125 deposit prior to review. ***BOXED AREA.EHD USE ONLY*** <br /> t i — <br /> -1 5' I MPFo,- l0Lf3� ?n ..ue„wWLsf z * <br /> n <br /> ❑ Records provicid by Staff-PPR Co plete.staff Name: <br /> EHD 4646 q/pgitq <br /> /�Ie /,t;l71Z- /�7y <br />