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MAR.10.2005 10:59AM APEX ENVIROTECH,INC. NO.289 P.1 <br /> DATE RECEIVE[) � '"OW, EHD LOC NUMBER � <br /> SAN.�OAQUPi T COUNTY <br /> EwiRdNMENTAL HEALTH DEPARTMENT � <br /> 304 East Weber Avenue,3d Floor, Stockton,CA 95202-2708 �55 i <br /> MAR 1 2��5 Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> EHY1R0NWMT HEALTH PUBLIC RECORDS RELEASE APPLICATION ���!!! <br /> T• 0"� BUSINESSIAGENCY,,_ - ALX <br /> ADDRESS: 'L'ia S.-kf'j'r,- D f ild, Tt,�d1Gl}C, Sk 9c'F3'6lr- <br /> PHONE(1): Pi{ONE(2): Vkl I."t16 —ab LII" FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE.- AA` ��•�-��J -_—Time: 4� 402zl <br /> (Please allow 10 business days from date of application submittal-*Tentative only-must be confirmed) <br /> ❑ CHECK SOX TO EXPEDITE REQUEST.$93.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSPO iN 3 SUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE 3 40/0 � <br /> UNIT DISTRIBUTION ❑ unit 1 ❑Unit 2 q Unit 3 AnA4 jVIjnIt5 E3 Unit 6 0 Other(alactronWlistrdmaps) <br /> FILE ADDRESS EHD USE ONLY <br /> $trent# Straot Name City <br /> 2. <br /> 3. 4 M,-a— ShacbC cJ <br /> 4. t�.t8 l-1� ti.rr► 4 ter '' h 31�. <br /> s_ q511 t4_ <br /> ck'Ad IS h r h1 <br /> 10. <br /> SpeciFC Date Range of Information Requested:From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> rUNOERGKOUNO TANK(UST)C�EANup SITE(LOP) C3 HOUSING ABATEMENT p SoND WAsm FAcUNIVEHICLE <br /> Cl OTHER CiY_!o.NUp SITE(NON-LOP) <br /> ❑FOOD FACILITY C3 WASTE TIRE <br /> ❑UNDEKaROUND TANK(MONITORINGIREMOVAL) 0 DOG KENNEL ' E3 DAiRY <br /> E3 HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH A WASTEWATER TREATMEW PLANT <br /> ❑TIERED PERMITTED FACILITY ❑MoTEUHoTEI ❑PuMpERTRUcWAKDICHeM TOILETS <br /> Q TATTOO(BODY PIERCING t7 POOL/SPA E3 LAND U3F APPLPCATION,SITES <br /> ❑MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PFRMIT REcoRAs ARE AVAILABLE FOR REVIEW- MONDAY-FRIDAY 0,00 AM•5:00pN - EXCLUDING HOUDAY5. <br /> i, List up to ten addresses in the space above, Select the type(s)of files from the list above by checking the <br /> appropriate box(es). At least one file type MUST be selected. Fax to 209)464.0138 or mail to the address <br /> indicated above. Address ranges will not be accepted-for additional assistance with file addresses, contaci <br /> the EHD.Applications received after 3:00 pm will be processed the next business day. <br /> 2. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> approximately ten (10) days after receipt of application. The files will be held for a maximum of five business <br /> days for review, Appointments should be scheduled accordingly. <br /> 3. A file that is actively being worked on by EHO staff may not be immediately available for review. A new <br /> i application may be submitted when the file is available. <br /> 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the <br /> applicant. Future file reviews by the same applicant may require a$93.00 deposit prior to review. <br /> EHD as-o2aae <br /> 1H4/es <br />