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_ EHD LOG NUMBER <br /> F;T CE13E° SAN .IOAQUIN COUNTY <br /> t" r I�f - n� <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> DEC 215 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT:Uo\t� Mk���A L`Ntb 13USINESSIAGENCY: \7e�\S( R FtSS0�1RIES, 111L. <br /> ADDRESS: P p�01C 3 L CITYISTATEIZIP: ' \j luC_ <br /> q, i FAX OR E-MAIL: tM,A'\t bY�1C(�1�1S5DUA S. <br /> PHONE(1): X1\0 Ltl C 1�� PHONE(2): ` <br /> Please allow 10 business days from date of application submittal for the records to be available. C GVv <br /> Staff will contact you to arran a an appointment date and time to review the requested records. <br /> ❑CHECK BOX TO EXPEDITE RE UES 130 FEE AS OR C CK��n Y}z REQUEST PROCESSED IN 3 BUSINE S DAYS <br /> SIGNATURE OF APPLICANT _P ft I 6, DATE \V 13 �6 <br /> Electronic Information: ❑ List❑ Map–Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name city ❑unit 1 <br /> 2. 1 C� S Nw`I 'AG\ W%N Nbt �-D STO0K_\Q lrovIA C-D <br /> 3• 3233 1.00 N1�S V-D S�oC -'1 o N �4�`"� °u"'t` <br /> 4. ti�21 s N k�wVy % FR�NT�G� p D� sT{o( TbN p t1-31-t� ❑unitZ <br /> 6 2�'�` 7�,c\/�wy l- 1 ��Q��r`(:� 1'-Il S \�(,k—�bMN' I"tOi — E�'tlnit 3 I I1�1.{ <br /> 6. 3\12 \.�V\\� �n ��C�f—'��\V �E� Unit 3HM 1 ` <br /> nt <br /> 7. , N2c� S \A N' sT�oC�(TG`� I D �J L �J� <br /> PF T —uJ ITEMITIGATION <br /> 9. <br /> ❑Unit <br /> 10. <br /> Specific Date Range of Information Requested: From to <br /> �y ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> Ly UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MOTELIHOTEL [I SOLID WASTE FACILITYIVEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑FOOD FACILITY <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑WASTE TIRE ❑DAIRY,POOL/SPA <br /> ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTE ❑MEDICAL WASTE FACILITY ❑PUMPER TRUCK/YARD/CHEMICAL TOILETS <br /> HAZARDOUS MATERIALS ❑TATTOO/BODY PIERCING ❑LAND USE APPLICATION SITES <br /> 21 TIERED PERMITTED FACILITY ErCOMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW' MONDAY-FRIDAY 8'00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> 1. List Uo to ten addresses in the space above. Select the typo(s)of files from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(2091464 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$130 deposit prior to review. <br /> —BOXED AREA-EHD USE ONLY' <br /> pti. c <br /> i.or 7-lot tv °It 1 `1 od iH Lk A r`,�,J Qe.ok <br /> CA(P oktti ( Q. <br /> 0 Records provided by Staff-PPR Complete. Staff Name: <br />