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DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> l0 / ENVIRONMENTAL HEALTH DEPARTMENT k <br /> 3;16 p Il 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> - - - — -- <br /> - Telephone:-(209)468=3420-Faz:-(209)464=0138 Web:www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: V I ju 1 *,i, 0064 BUSINESS/AGENCY: <br /> ADDRESS: S2-I2- IU, %/Zd C Y ,ti LVIJ 11 2Z CITY/STATE/ZIP: 7-K,4 CY , <br /> PHONE (1): Y) -- /,f7- %?Y� PHONE (2): FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: -4 j,j Time: <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BU [NESS DAYS <br /> SIGNATURE OF APPLICANT `,���,= '�J�j�t�zr` �C DATE 67���j; <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name City ❑ Unit 1 <br /> 2. 70" A ❑ Unit 2 <br /> 3. n/ <br /> 4. <br /> -❑ Unit 3 � <br /> 5. <br /> 6. []U�. <br /> nit 4 -� <br /> 7. <br /> a. <br /> ❑ Unit 5 i <br /> s. D -718//3 <br /> 10. <br /> ❑Unit 6 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ©UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYIVEHICLE <br /> ©OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> M UNDERGROUND TANK(MONITORING/REMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> 0 ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> 0 HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> 0 TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOO/BODY PIERCING ❑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-for additional assistance with file addresses,contact the EHD. Applications received after <br /> 3:00 pm will be processed the next business day. <br /> 2. 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 /> .3. A file that is-actively being worked on by EHD staff may not be immediately available for review. A new application may be <br /> 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 applicant. <br /> Future file reviews by the same applicant may require a$125 deposit prior to review. ***BOXED AREA-EHD USE ONLY*** <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 48-06 <br /> 914112 <br />