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IMCIUVED <br /> SAN JOAQUIN COUNTY . EHD LOG NUMBER <br /> OCT 11 2016 ENVIRONMENTAL HEALTH DEPARTM t0 )2 jtV q38&- <br /> WAPPLICANT: <br /> 1: (2 East Hazelton Avenue, Stockton, CA b: www.sjglov.org/ehd <br /> EM/IROAb4ENTAL HEALTH Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> PERM PSERVICE1S_ PUBLIC RECORDS RELEASE APPLICATION <br /> NlohvlQS S611divar BUSINESS/AGENCY: <br /> ADDRESS: CITY/STATE/ZIP: iq7lo <br /> PHONE(1): 010,2-13,- 3 1pl t) PHONE (2): FAX OR E-MAIL: <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-$139 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> 1. List up to ten addresses in the space below. Select the type(s) of files from the list below 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 $139 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List ❑ Map—Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES EHD USE ONLY <br /> UNDERGROUND TANK(UST) Street# Street Name City <br /> CLEANUP SITE(LOP) LoO CONSVMER <br /> Claalh J�fie� <br /> S - o(" r�aoN <br /> 1dOTHER CLEANUP SITE(NON-LOP) I <br /> HAZARDOUS WASTE ///��� ^/ I n <br /> ❑T RED PERMITTED FACILITY 2 I I S / h A(/ 1 ��u t Lodi O�f, ❑DAIRY <br /> ABOVEGROUND TANK (�' I V, Vr 1 U I ( t�(� (� (�l( <br /> [VUST (MONITORING/REMOVAL) ❑PWS <br /> 21HAZARDOUs MATERULs B <br /> �SPILL/RELEASE RESPONSE <br /> SOLID WASTE FACILITY/VEHICLE 4 WATER OUALItt <br /> FOOD FACILITY <br /> ❑POOL/SPA SITE MRK ATION <br /> ❑DAIRY 6 <br /> ❑LAND USE APPLICATION SITES <br /> ❑SEPTIC PUMPER TRUCK/ 6 ❑HOUSING <br /> YARD/CHEMICAL TOILETS <br /> WASTEWATER TREATMENT PLANT CUPA <br /> ❑HOUSING ABATEMENT 7 <br /> ❑MoTEVHoTEL <br /> ❑CHICKEN RANCH/DOG KENNEL CUPA-UST <br /> 6 <br /> MEDICAL WASTE FACILITY <br /> ❑TATTOO/BODY PIERCING E]SOLID WASTE <br /> ❑WASTE TIRE 9 <br /> ❑COMPIAINT <br /> )]OTHER(PLEASE SPECIFY): 11 AccourvTmO <br /> tD <br /> "`BOXED AREA-EHD USE ONLY"' <br /> TE3 <br /> Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 48-06 <br />