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DATE RECEIVED \ I L NUMBER <br /> �.- SAN JOAQUIN COUNTY ,.i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Hazelton1868 East <br /> Telephone: (20) 468-3420 Fax:(209)464-0138 Web: www.sigov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> / ' S -C;>Vt Y.I 6 . u I i <br /> le- <br /> APPLICANT: e-7>� (-11JA BUSINESS/AGENCY: Cf uc.TiA)6- 1ST <br /> ADDRESS: / �/ptJgUD�}� ��) (/�'i tCITY//S/TAT/lE/ZIP: I U,�JOrD.G� cp 9��� cS <br /> PHONE(1): `j��/— /—�yZ/ PHONE(2): 21)9-4 Q1—(pUIg7 FACSIMILE: O '-3C Sig <br /> 4 <br /> Please allow 10 business days from date of application submittal for the records to be availagle. <br /> Staff will contact you to.arrange an appointment date and time to review the requested records. <br /> ❑CHECK BOX TO EXPEDITE REQUEST $125 FE (CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUST ESS D S <br /> SIGNATURE OF APPLICANT e'4—�- DATE <br /> Electronic information: ❑List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street S Street Name city <br /> "l\ ❑Unit1 <br /> 2. -7rVP�IU 1 I USS ' -Unit2 <br /> 4. l <br /> Unit 3 <br /> 6. <br /> 6. <br /> Unit 4 <br /> 7. <br /> 8. ❑Unit 5 <br /> 9. <br /> 10. <br /> El Unit 6 <br /> Specific Date Range of Information Requested: From to �99 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES l �� <br /> F]UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACIUTYIVEHICLE 1 (',Di <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRY d <br /> ❑ABOVEGROUND TANH1 t 1 <br /> ❑CHICKEN RANCHID00 KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ❑HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICALTOILETS <br /> ❑TIERED PERMITTED FACILITY ❑POOL/SPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOOIBODY PIERCING ❑COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00pm(EXCLUDING HOLIDAYS) <br /> 1. List up to ten addresses in the space above. Select the type(s)of files from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(209)484-0138 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$125 deposit prior to review. `" EIOXED AREA-EHD USE ONLY"* <br /> 1 t l I o,ck-ad ]- XS�-019 `S , pllc a.1 C-®_ <br /> iet,3 Lor c OrThere' t4 W It p `O no l <br /> ❑ Rec rds provided by S ff-PPR Complete. staff Name: <br /> EHD N-06 <br /> azena <br />