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GATE RECEIVED PHO LOG NUMBER <br />1we SAN JOAQUIN COUNTY .ftw <br />ENVIRONMENTAL HEALTI3 DEPARTMENT <br />304 E Weber Ave 3"t Floor Stockton, CA 95205 <br />2 <br />(209) 468-3420 Fax: (209) 464-0138 Web: www.co.san joaquin.ca, e�� <br />PUBLIC <br />(' RECORDS RELEASE APPLICATION <br />APPLICANT: h AW)1, 744 %6-{ _ <br />• - <br />ADDRESS: <br />PHONE: 7tg "1 - �JL� 4 FACSIMILE: 3,IR CI "i -Z 'd <br />TENTATIVE* APPOINTMENT DATE: (� 1� ( / 0 Time: �' Cy -0 <br />(Please allow 10 business days from date of applicationI <br />CHECK BOX TO EXPEDITE REQUEST- $93.00 FEE - REQUEST PROCES c U DAYS <br />SIGNATURE OF APPLICANT DATE <br />Department Use Only <br />3fab3 ENVIRONMENTAL H96a TH DEPPAR NT FILrk <br />101 <br />UNIT <br />❑ Unit 1 <br />p Unit 2 <br />Unit 3 <br />ltf%� Unit <br />//[) Unit 5 <br />W UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />FILE ADDRESS <br />.alm;l <br />2�ID ^r � of lTn. <br />slrocl <br />27-ge 10c <br />112. <br />yid slrcH <br />slm <br />�f2.&sQr�6O �$ -4 - I \W t 1 <br />7- , o ^ S �`"p' 60 j sin,40I 6f 1 <br />sU�.lX51 <br />s f� • •C. d t <br />6, SIICeI <br />l� <br />7-Z .�•�,.wr. %t.0 <br />all <br />2-431 "Aa hl ' 4C4YG It DC' G1 <br />srceel <br />2.'2-3oSti •' ' of <br />0 . sl,Ml <br />21 S-0 cSc. P . <br />Peet <br />•2'f 91 1 r " O%0.K4I <br />3fab3 ENVIRONMENTAL H96a TH DEPPAR NT FILrk <br />101 <br />UNIT <br />❑ Unit 1 <br />p Unit 2 <br />Unit 3 <br />ltf%� Unit <br />//[) Unit 5 <br />W UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />HOUSING ABATEMENT <br />❑ SOLID WASTE FACILITY <br />X OTHER CLEANUP SITE (NON -LOP) <br />❑ <br />FOOD FACILITY <br />❑ SOLID WASTE VEHICLE <br />&i UNDERGROUND YANK (MONITORINGIREMOVAL)✓ <br />❑ <br />DOG KENNEL <br />❑ DAIRY <br />8t HAZARDOUS WASTE GENERATOR-' <br />❑ <br />CHICKEN RANCH <br />O PKG TREATMENT PLANT <br />TIERED PERMITTED FACILITY ✓- noAG <br />❑ <br />MOTELIHOTEL <br />❑ PUMPER TRUCK/YARD/CHEM TOILETS <br />4 TATTOOIBODY PIERCING <br />❑ <br />POOUSPA <br />❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY <br />❑ <br />OTHER (PLEASE SPECIFY) <br />1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking <br />the appropriate box(es). At least one file type MUST be selected. Fax to 209 464-0138 or mail to the <br />address indicated above. <br />2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br />approximately five business days but no later than ten (10) days after receipt of application. The files <br />will be held for a maximum of five business days for review. Appointments should be scheduled <br />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 returned in the same condition as released will be reorganized by EHD staff at the expense <br />of the applicant. Future file reviews by the same applicant may require a $93.00 deposit prior to review. <br />5. *TENTATIVE appointment dates must be confirmed with EHD staff. <br />6. Applications received after 3:00 pm will be processed the next business day. <br />CONFIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX INITIALS <br />REVIEWED YES NO REVIEW DATE <br />elan a9.e24e9 ""' •--- <br />