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DATE RECEIVED „ EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> l n J ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:wvvw.sjgov.org/ehd 1 <br /> PUBLIC RECORDS RELEASE APPLICATION i <br /> I <br /> APPLICANT: ED LUGL-t(E,sl BUSINESS/AGENCY: h'I. <br /> ` <br /> IfCO a <br /> ADDRESS: ,26-17 S, Al2P02T kJA y CIF ISTATEIZIP: L"A. CS'7e,K, I <br /> PHONE(1): 701- `792- 11,47-` PHONE (2): Zd - r! 'Z —116 FACSIMILE:Zv17- q'0'Z-0/Zo j <br /> Please allow 10 business days from date of application submittal forthe 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-$12 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS j <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information: [Bfist)R101ap—Description: 200 ^j. Q L CKMj9^1 <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City _ ❑Unit1 <br /> 1. 200 N• 66e14141A 1 i2/a. G 6'0 IQ=O <br /> 2. q 2 J, ru c7-1 "A '•Lkf- ❑Unit2 <br /> 3. <br /> 4• j6Unit 3 <br /> 6• Unit4 <br /> 7 � <br /> 7. <br /> i <br /> $• ❑Units <br /> 9 � <br /> 10• ❑Units <br /> Specific Date Range of Information Requested: From 99g to - zc7/, <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> U DERGROUNDTANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYIVEHICLE <br /> I <br /> IR CLEANUP SITE(NON•LOP) ❑HOUSINGABATEMENT ❑WASTE TIRE <br /> RGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRYEGROUNDTANK ❑CHICKEN RANCH/DOG KENNEL ©WASTEWATER TREATMENT PLANT <br /> DOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ©PUMPER TRUCKIYARD/CHEMICAL TOILETS <br /> ❑TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOOISODY PIERCING ❑':COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-6:00PM(EXCLUDING HOLIDAYS) <br /> 1. List uo 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(2091464-0138 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 p6br to review. **'BOXED AREA-EHD USE ONLY*"* j <br /> i <br /> i <br /> i <br /> i <br /> ❑ Records provided by Staff-PPR Complete.Staff Name: 1 <br /> EHD a6 6 V28114 <br /> J <br /> 7 <br />