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DATE RECE VED, EHD LOG NUMBER <br /> q <br /> ENVIRONSAN JOAQUIN COUNTY <br /> MENTAL HEALTH DEPARTMENT 7cl7 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 55 <br /> of {G/T) "" Telephone- (209) 468-3420 Fax: (209) 464-0138 Web:wv✓W.sjgov.orglehd <br /> 11A PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESS/AGENCY:` n2�"�e'' u urMMer+&_L <br /> ADDRESS: �i � ►rba v'f"Ade�'a Bv,,�,-; - CiTYISTATE/ZIP:_5� ►'I( � i5 t,� <br /> PHONElZt PHONE(2): 9-D9®29$-88&0) FACSIMILE: <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-$130 FEE(QAZH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESSDAYS <br /> SIGNATURE OF APPLICANT DATE L'�5 <br /> Electronic Information: ❑List❑ Map-Description: <br /> FEND USE ONLY <br /> FILE ADDRESS <br /> Street# Street Name City <br /> r2' <br /> 1. ��r�'''c. <br /> a 0. .0 l B y ❑Unit 2 ` {J <br /> 4 •Unit 3 <br /> N /�y Unit 4 <br /> 7. <br /> 8. 0 Unit 5 <br /> 9. <br /> 10 1 ❑Unit 6 <br /> Specific Date Range of Information Requested: From let (o$ to z2c L <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> Fvj UNDERGROUND TANK(UST)CLEANUP SITE(LOP) F1 MEDICAL WASTE FACILITY ❑SOLID WASTE FACILIiYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> ®UNDERGROUND TANK(MONITORINWREMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ©ABOVEGROUND TANK ❑CHICKEN RANCHI DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ®HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICAL TOILETS <br /> ®TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑TATT00I130DY PIERCING ❑COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEvd: MONDAY-FRIDAY 8:00 AM-5:0012M(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.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 requh'a a$130 deposit prior to review. `�BOXED ARP n-IEHO USE ONLY*`" <br /> m i=4tesard� provided by St�aTfm�'PE-"I Carrip ete. staff Name: <br /> _ <br /> ------. <br /> 0!D 08101 a <br /> 48-01 <br />