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5 -W"'It�I 5 PM Ha os Environmental , Inc 51 349098 p. l <br /> I■■ v EHD L00 NUfAeER <br /> ■ ATE RECEIVED <br /> i ■ SAN .IOAQUIN COUNTY <br /> �■ JAN 27 2015 ENVIRONMENTAL HEALTH DEPARTMENT �h�O <br /> ENVIRONMEN-!AI—[�I� 1868 East Hazelton Avenue, Stockton, CA 95205-5232 <br /> PERMITfSERVIC 001 one: (209)468-3420 Fax: (209) 484-0138 Web: vvvw.sjgov,org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: SAM LOG,? RUSINESS/AQENCY: %kstz-S 1<n�y QeA�M6/7TAL,IJG, <br /> ADDRESS: 65S IZTN ?TR6GT 1 S,,,rt- 126 \ CITY/STATE/ZIP: OAKLAa0t CA Cl 4 6p+ <br /> PHONE (1): 101034-'.°1o9q _ PHONE (2): FACSIMILE: (rit,) BILJ ,0018 <br /> Please allow 10 huslness days from date of application submittal for the records to be available. <br /> Staff will contest you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REOU -$130 FEE(CAS R CHECK ONLY)-REQUEST PROCESSED IN a BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE 1 (-441 IS <br /> Electronic Information: ❑ Llst ❑ Map- Description: <br /> FILE ADDRESS RHD USE ONLY <br /> Street# Street Name City Unit 1 <br /> 1. 17.5 15 CO__..ca C-L o�K a.1 IfJJ <br /> 2. M4'2U1112 <br /> 3. <br /> 4. l—) 1-15 units <br /> & lJnll4 <br /> 7. <br /> 8. Unit 6 <br /> 9. <br /> iJn it e <br /> SpeG(lo Date Range of Information Requestad: From to <br /> �/ <br /> ENVIRONMENTAL HEALTH DEPARTMEiNT PILES ,—� <br /> ��NI DEROROUNDTANK(UST)CLEANUP SITE(LOP) u 1'IEDICAL WASTE FACILfrY L—_I.S9LID WASTE FACILITYNEHICLE <br /> Q'THER CLEANUP SITE(NON!-LOP) ❑HOUSING ABATEMENT 3VASTE TIRE <br /> C�=JJj'k.DEROROUND TANK(MONRORINOIREMOVAL) ❑FOOD FACILITY ❑ DAIRY <br /> BOVEOROUNDTANK ❑CHICKEN RANCW DOB KENNEL ASTEWATER TREATMENT PLANT <br /> RDOUS WASTEIHAZARDDUS MATERIALS ❑MOTELIHOTEL uMPER TRUCKIYARDICHEMICAL TOILETS <br /> ERED PERMITTED FACILRY ❑POOUSPA LAND USE APPLICATION SITES <br /> ❑TATTOWBODY PIERCINQ, ❑COMPLAINTIRESPON86 RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-6:00PM(EXCLUDING HOLIDAY@) <br /> 1. List ue to ten taddretft In the awe above. Select the type(s)of fIlse from the[let above by checking the appropriate <br /> box(es)- At least oris}Ile type MUST be selected. Fax to(20 )484-0138 or mall to the addra" Indicated above. Address <br /> ranges will net t»accepted.Application• received after 3:00 pm will be proeeaesd the next business day. <br /> 2. For aseletnnce 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 11 any EHD Mae exist. An appointment for review will be confirmed approximately ten(10) <br /> days atter recelpi of appiluallon, The (Ilea will beheld for a maximum of five business days for review. Appolntmente <br /> .should be scheduled accordingly. <br /> 4. Any file not returned In the same condition as released will be reorganised by EHD staff at the expense of the applicant. <br /> Future flle revlant hy'ha name applicant may require a $130 depoeh prior to review. `13OXED AREA• HD USE ONLY"' <br /> ❑ Records provided by Staff•PPR 4:6mptets. staff Name: <br /> Received Time--Jan, 26.2015= 4: 54PNi=No._7Q.5.8--""�" — "— ""` <br />