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DAc ` ~W SAN $fOAQUIN COUNTY EHD LOG NUMBER <br /> ENVIRONMENTAL HEALTH , CA <br /> .� <br /> SEP Z 6 206 1868 East Hazelton Avenue, Stockton, CA 95205-6232 WAv \ /��� (J,� <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: w.sjgov.org/ehd }vim <br /> EWRONMENTALHEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> �PP�LI-C€ANT; b ('1 T6�r�Z BUSINESS/AGENCY:Lctz��)p � <br /> ADDRESS: (�� '�,C>3 CITY/STA.TE/=[P: N `l <br /> PHONE (1): aO,i (,O,� —0'7Ua PHONE (2): FAX OR E-MAIL: `7 v <br /> Please allow 10 business days from date of application submittal for the records to be available, <br /> tt�s <br /> Staff Will contact you to arrange an appointment date and time to review the requested records. � <br /> ❑ CHECK BOX TO EXPEDITE QUEST-$1 FEE (fL�$k{OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSIWESS DAYS <br /> SIGf.ATURE OF APPLICANT �� (/V 4fj DATE <br /> 9. List up to ten addresses in the space below. Select the type(s) of files from the list below by checking the ap ropriate <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$139 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PIA(EXCLUDING HOLIDAYS) <br /> Electronic tnforr-nation: ❑ List ❑ Wiap—Description: f <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT c a E ADDRESS <br /> p gg ppl�cc ��`` �y <br /> FILES e Prete EHD € SE O'€SIL € <br /> UNDERGROUND TANK(UST) Street# Street Name City <br /> LT CLEANUP SITE(LOP) <br /> OT HER CLEANUP SITE(NON-LOP) <br /> HAZARDOUS WASTE <br /> DAIRY <br /> TIERED PERMITTED FACILITY 2 <br /> ABOVEGROUND TANK _ ,�CO <br /> UST (MONITORING/REMOVAL) v� E]PWS <br /> HAZARDOUS MATERIALS B <br /> SPILVRELEASE RESPONSE <br /> SOLID WASTE FACILITY/VEHICLE 4 w-TER DUALITY <br /> FOOD FACILITY <br /> POOL/SPA <br /> SITE MITIGATION <br /> DAIRY S <br /> LAND USE APPLICATION SITES " <br /> O <br /> SEPTIC PUMPER TRUCK/ HUSING_ 6 <br /> YARD/CHEMICAL TOILETS <br /> WASTEWATER TREATMENT PLANT <br /> CUPA <br /> HOUSING ABATEMENT 7 <br /> MOTEUHOTEL <br /> CHICKEN RANCH/DOG KENNEL CUPA-U$T <br /> B <br /> MEDICAL WASTE FACILITY <br /> TATTOO/SOOY PIERCING <br /> SOLID WASTE <br /> WASTE TIRE e <br /> COMPIAINT <br /> ❑OTHER(PLEASE SPECIFY): ACCOUNTING <br /> 10 <br /> '—BOXED AREA-EHD USE ONLY.. <br /> MW <br /> ❑ Records provided by Staff-PPR Complete. staff Name: <br /> EHD 48.06 <br />