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DATE RECEIVED ., EHD LOG NUMBER <br /> _ I § SAN JOAQUIN COUNTY <br /> F " - . <br /> C 14 m ENVIRONIl4EPJTAL HEALTH CEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> L�bP Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd t <br /> PUBLIC !RECORDS RELEASE APPLICATION <br /> (I }dVddC9 —' 'E'' <br /> ��IIj{c i^n y{y�Y}7(� S BUSINESS/AGENC" RQPi ��gn _ <br /> ADDRESS: 1pQQ R-Im1f1f (✓ CfTI'/STATElZIF: FHe_ tl L i C f} 6­7 57 <br /> PHONE (1): Ml M—I P (y PHONE(2): FAX OR E-MAIL: tf ffeco. rea(JRWINAt, <br /> Please allow 10 business days from date of application submittal for the records to be available. Coro <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 $1339 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM•5:00PPIi(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List ❑ fticap— Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES EHD USE ONLY <br /> 10 UNDERGROUND TANK(UST) Street# Street Name City <br /> CLEANUP SITE(LOP) ��` rho�` 1O (AT- 1'y ❑CONSUMER <br /> U 1^VI IV/ VVJi1TV(vIY�A7IVY ' � <br /> OTHER CLEANUP SITE(NON-LOP) IZ <br /> HAZARDOUS WASTE ❑DAIRY <br /> ❑TIERED PERMITTED FACILITY 2 <br /> ABOVEGROUND TANK <br /> ®r UST (MONITORING/REMOVAL) ❑PWS <br /> ❑HAZARDOUS MATERIALS 3 <br /> ❑SPILURELEASE RESPONSE WATER ODUTY <br /> ❑SOLID WASTE FACILITY/VEHICLE 4 <br /> ❑FOOD FACILITY <br /> POOL/SPA Ei"S'TZ MITIGATION <br /> ❑ <br /> ❑DAIRY 6 <br /> ❑LAND USE APPLICATION SITES Housm <br /> ❑SEPTIC PUMPER TRUCK/ 6 <br /> YARD/CHEMICAL TOILETS <br /> ❑WASTEWATER TREATMENT PLANT ❑CUPA <br /> ❑HOUSING ABATEMENT T <br /> ❑MOTEUHOTEL CUPA-UST <br /> ❑CHICKEN RANCH/DOG KENNEL <br /> 8 <br /> ❑MEDICAL WASTE FACILITY <br /> ❑TATTOO/BODY PIERCING ❑SOLID WASTE <br /> ❑WASTE TIRE 9 <br /> ❑COMPLAINT <br /> ❑OTHER(PLEASE SPECIFY): ❑ACCOUNTING <br /> 10 <br /> '•'BOXED AREA-EHD USE ONLY— <br /> ❑ Records provided by Staff-PPR Complete. staff Name: <br /> END 48-06 <br />