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DATE RECEIVEDRECEIVED 1tf' EHD LOG NUMBER <br /> FEB 1 �Ot6 SAN JOAQUIN COUNT <r 'A E <br /> ENVIRONMENTAL HEALTH DEP f� NTNO <br /> ��NFAf NTALHEAUp 868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • -MITAII tef(209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.ora/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICAt�k:- 'C 1� �� �G� .- - SUSI6JESS/AGENCI': <br /> ADDRES —___'Z CITY/STATE/ZIP: �/ a?C✓�i �_ 45­7-:,� <br /> PHONE (1): 2-4 4�31- ZgjDri.. PHONE (2): FAX OR E-MAIL: ✓ (fc1L✓ ¢Vr <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 <br /> Electronic Information: ❑ List❑ Map\Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street# Street Name City <br /> 1. U .�1 �� t Lopi'fwl,"-Lo ❑ unit 1 <br /> 2. <br /> 3• nit 2 <br /> 4. (� El unit 2H Zi(� <br /> 5. %r(�nff ��nit3 <br /> • 6. �-�I U'�p 2111 it 3HNI M1' <br /> 7• ❑ Unit <br /> B• q4ITE MITIGATION <br /> 9. <br /> 10 [IUnit s <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> NDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MOTEUHOTEL ❑SOLID WASTE FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑FOOD FACILITY <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑WASTE TIRE ❑DAIRY,POOUSPA <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> F1 HAZARDOUS WASTE E]MEDICAL WASTE FACILITY ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ffktAZARDOUS MATERIALS ❑TATTOO/BODY PIERCING ❑LAND USE APPLICATION SITES <br /> ❑TIERED PERMITTED FACILITY ❑COMPLAINT/RESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> ` WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY•FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> 1. List u0 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)464-0138 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$130 deposit prior to review. <br /> Aft ***BOXED AREA-EHD USE ONLY*** <br /> Alyv'391 LDP `le Ao/ IV'-( JAf l ylit CO. <br /> 0 Records provided by Staff-PPR Complete. Staff Name: <br />