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DATE RECEIVED SAN .10AQUIN COUNTY EHD LOG NUMBER <br />�j' J <br />rf %���{ ENVIRONMENTAL HEALTH DEPARTMENT <br />GL 7' <br />A( 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/eh <br />'!LE COknY <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: (..O LIeeVA <br />BUSINESS/AGENCY: Q—QS�5?�.��.�2 C -A , <br />ADDRESS: V35 S - LWS_a- <br />1 k q:�,_ :SSOO <br />CITY/STATE/ZIP:CA, '7. o <br />, I>r (�OloO- <br />PHONE (1): '7dkZ.Z b2. —S&S <br />PHONE (2): <br />FACSIMILE: <br />'3 12.�;L kk <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 Q DATE %LZ A 4 <br />Electronic Information: ❑ List ❑ Map — Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />❑ Unit 1 <br />Street # <br />Street Name <br />City <br />13o0 <br />�] Unit 2 <br />2. <br />l'302 <br />,• ,. <br />,. ,. <br />3. <br />.Eunit 3 <br />4. <br />5. <br />J]�Unit 4 <br />6. <br />7. <br />❑ Unit 5 <br />8. <br />9. <br />E] Unit 6 <br />10. <br />X L <br />Specific Date Range of Information Requested: From 1. L_ to <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES j <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) [:1 MEDICAL WASTE FACILITY SOLID WASTE FACILITYNEHICLE /UP , <br />OTHER CLEANUP SITE (NON -LOP) ❑ HOUSING ABATEMENT ,WASTE TIRE <br />UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ FOOD FACILITY ❑ DAIRY <br />ABOVEGROUND TANK ❑ CHICKEN RANCH/ DOG KENNEL WASTEWATER TREATMENT PLANT <br />HAZARDOUS WASTEMAZARDOUS MATERIALS ❑ MOTELIHOTEL ❑ PUMPER TRU CKIYARDICHEMICAL TOILETS <br />TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br />❑ TATTOOIBODY PIERCING C;I'COMPLAINTIRESPONSE 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(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. ***BOXED AREA - EHD USE ONLY*** <br />❑ Records provided by Staff -PPR Complete. Staff Name: <br />EHD 48-06 <br />