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III Rrc I [uuo [ 5(rm c taRIH TECH N0. 5926 P 2 <br /> 4A"- REG��I,VLD(—',Ji <br /> SAN JOAQUIN COWiTx EHD LOG NUMBER <br /> MA 4 a i - <br /> ENvIRONmNTA.L HEALTH DEPARTMENT 7 <br /> 304 East Weber Avenue 3r1Floor Stockton,CA 95202-2708 1� � <br /> ENb'fl<;UNPERk"Ifl?-, I Ii--1Z, Telephone: 209 468-3420 Fax:(209)464-0138 Web:www.sT ov.or [ehd� <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: Q� �A! N SIN AGENCY: Tpo <br /> ADDRESS: qq,,(��^^pY/ ,,rr pp1\ �(,t .y�,�I� .Y FF� <br /> PHONE(1):olA -1% ,PHONE(2): - Q - 01- DCOZ- ACSIMILE: %*07 Y, <br /> TENTATIVE*APPOINTMENT DATE: a2 D(a Time: ) '3019111 <br /> (Please allow 10 business days from d o 'cation submittal-'TentaOYD only-must be rnnfllmed) <br /> CHECK BOX To EXPEDITE RE T-$95.0 FEE( CHECK ONLY)-REQUEST PROCESSED IN I BU 1NESS DAYS <br /> SIGNATURE OF APPLIC T DATEA7 10� <br /> UN17 bIST1 IBUTION ❑Unit1 ❑Unit2 ❑Unit Unit4 13 units O Units ❑ Otbar(alsctroniogistslmaps) <br /> FILE ADDRESS <br /> Street a'K street Name EHDUSE <br /> 1. LI p r <br /> 2. t A <br /> 3, p It <br /> 4. N440NLY <br /> S. 0 .a �Q' r <br /> 6. cneo p s 11 �rj <br /> 7• 7a 9Sc7y1� <br /> 3• D �rtoc.t. <br /> 9. ID tor. <br /> 10. 2 <br /> Specific Date Range of Information Requested:From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) E3 HOu51NGADATENIGNT 'ErSOLID WASTE FACILnYNEMICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑PDOD FACILITY E SOLIDWASTTIRE <br /> NOEAOROUNO YANK(MONITORING/REMOVAi) ODOG KENNEL ❑DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH E3 WASTEWATER TRGATMENTPLANT <br /> TIERED PERMITTED FACILn ❑MOTELIHOTEL ❑PUNPER TRUOKII'ARDICHEM TOILETS <br /> ❑TArTDD/BOOP PIERCING ❑POOLI$PA �( <br /> ❑MEDICAL WASTE FACIUTY 13 OnIER(PLEASE SPECIFY) Jd LAND USE APPLICATION SITES <br /> WELL AND SEPTIC PERMn RECORDS ARE AVAILABLE FOR REVIEW- MONOAY-FRIDAY 8:00 AMS:OOPM - EXCLUDING HOLIDAYS. <br /> 1. List up to ten addresses in the space above. Select the type($)Of flies from the list above by checking the <br /> appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the,address <br /> Indicated above. Address ranges will not be accepted-for additional assistance with file addresses, contact <br /> the EHD.Applications received after 3:00 pm will be processed the next business day. <br /> 2. The EHD will notify the applicant If any EHO flies exist An appointment for review will be confirmed <br /> approximately ten (10)days after receipt of application. The files will be held for a maximum of five business <br /> days for review. Appointments should be scheduled 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 of the <br /> applicant Future file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> r <br /> TV <br /> EHD4UI.MG <br /> ItIa5 <br />