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SSM 09/21/2015 13:36 92574660�jp AEICONSLILTANTS PAGE 01/01 <br /> � ■ <br /> EHD LOG NUMBER <br /> ■ <br /> ° DATE RECEIVED SAN d JOA,(' UIN COUNTY <br /> RECEIVED. 3 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �� �l)i phone1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ale ; (209)468-3420 Fax: 209)464-0138 Web: www.sigov.org/ehd <br /> ENVIRONMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> FERIM t <br /> APPLICANT: `✓.�►�be'�t C>lM�"e'� BUSINESSIAGENCY: �lF� COf�J�t�1t <br /> ADDRESS: CITYISTATElzIP: Sh}a(►1V1� (;l"22K, CA Q4 � <br /> PHONE (1): RLS 79(0- Ca Ola PHONE(2):SID-(o Bl-78I Q FACSIMILE. <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$130 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS, <br /> SIGNATURE OF APPLICANT DATE O9/12-I X2015 <br /> Electronic information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name city <br /> 1. 2-si: i- v6&Pm; }e t We- u <br /> 2. WQSJ- NogevIlitie <br /> 3. p'tlnit 2 <br /> 4 ( talQl T7 C Q(tf Unit 2H <br /> AP <br /> s. <br /> -23-15 umt3 <br /> 7 Unit4 <br /> B SITE MITIGATION <br /> 3. <br /> t0 U It5 <br /> Speolfio Date Range of Information Requosted: From CAL to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES / <br /> DERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ID WASTE FACILITYNEHICLE <br /> 0 ER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ['WASTE TIRE <br /> DDERGROUND TANK(MONFORINGIREMOVAL) ❑FOOD FACILITY ❑D <br /> GROUND TANK ❑CHICKEN RANCHI DOG KENNEL ffND <br /> EWATER TREATMENT PLANT <br /> DOUS WA3TEIHA7ARDOUS MATERIALS ❑MOTEL/HOTEL ER TRUCKIYARDICHEMICAL TOILETS <br /> VIER72MO PERMITTED FACILITY ❑PAOLISPA USEAPPLICATION SRES <br /> ❑TATroo/BODY PIERCING LRtOMPLAtNr/RESPONSE 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(a)of files from the list above by checking the appropriate <br /> box(es). At least one file type MOST be selected. Fax to(209)464-0136 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 retumed in the same'condition as released will be reorganized by EHD staff atthe expense of the applicant. <br /> Future file reviews by the same applicant may require a 5130 deposit prior to review. `*'130AXED ARE -EHD USE9HLY'*' <br /> a Ltl .15-11g e/iL. A jiI.1 4:0 '14a, 1 ),-1 kA;L7 <br /> ✓ r�'��h,ie ola. <br /> CI Records provided by Staff-PPR Complete. Staff name: <br /> Received Time Sep, 21. 2015 1 : hFM No, 9609 '""9 <br />