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IISL '°N WJ Z tiI0 -0l 'A0N aUJI I P;AI ;D <br /> DATE RECEIVED EHD LOG NUMBER <br /> / SAN eIOAQUIN COUNTY <br /> I I '7 ,T17 <br /> -OP ENVIRONMENTAL HEALTH DEPARTMENT <br /> ' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 �� <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> " E O " Y <br /> PUBLIC RECORDS RELEASE APPLICATION C <br /> APPLICANT: K��A BUSINESS/AGENCY: <br /> ADDRESS; <br /> CITY/STATE/ZIP: C,k <br /> PHONE (1): PHONE (2): g1�, FACSIMILE: j((r' , ^ _7013 <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-SVP FE <br /> (�C.(C SH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT �, DATE 1I 10—f <br /> Electronic information: ❑ List❑ Map—Description., <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name city Unit 1 <br /> Unit 2 <br /> 3. <br /> 4. Unit 3 <br /> 5. lW CAWQf <br /> 6• %Unit 4 <br /> 7. <br /> 8• Unit is <br /> TOO I01�a <br /> Unit 6 <br /> Specific Date Rango of Information Requested: From to KL <br /> ENVIRONMENT L HEALTH DEPA TMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) [ EDICAL WASTE FACILITY OLID WASTE FACILITYIVEHICLE <br /> THEIR CLEANUP SITE(NON-LAP) [HOUSING [SABATEMENT ASTE TIRE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) OOD FACILITY AIRY <br /> dABovEGROUND TANK [CHICKEN RANCH/DOG KENNEL [/CWASTEWATER TREATMENT PLANT <br /> [HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL LIMPER TRUCK/YARDICHEMICAL TOILETS <br /> Q TIERED PERMITTED FACILITY ❑POOL/SPA 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 addresps 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 t4 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 END staff at the expense of the applicant. <br /> Future file reviews by the same applicant may require a$130 deposit prior to review. '"BOXED AREA-EHD USE ONLY— <br /> ■ <br /> ■ <br /> ® Records provided by Staff-PPR Complete. Staff Name: ■� <br /> EMD 48-06 ■ <br /> ��0010�114 ■ <br /> I r.fiin oNi VIn­1IJAITIIN IAI.JCI :C 4,1n7 •AI 'A r-) �■ <br />