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TOVED <br /> DATE R L EHD LOG NUMBER <br /> SAN AJOAQUIN COUNTY <br /> JUN ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,CA 95205.6232 <br /> • Telephon <br /> EiVVtRC'NMEidTAL HEALTH <br /> e:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.orglehd <br /> PEWAIT/S PUBLIC RECORDS RELEASE APPLICATION �r <br /> APPLICANT: tf,6 - 5 o"S!I,N�ESS(AGENCY: 7U `- CAr7 <br /> '[ rC1ItZL' . <br /> ADDRESS: i {' tt - •">IA/STATEIZIP: <br /> PHONE(1): � �� C11 PHONE(2): FAX OR E-MAIL: <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 EXP TE REOU-ST-£ 30 FEE(CAS OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT f.C• y;- t/�/L� DATE U-10^�I(J <br /> 1. List up to ten addresses in the space low. Select the type(s)of files from the list below by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to MOM 464-0138 or mall 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 flies 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 Ove business days for review. Appointments <br /> should be scheduled accordingly. <br /> 4. Any Ole not returned in the same condition as released will be reorganised by EHD staff at the expense of the applicant. <br /> Future Ole reviews by the same applicant may require a£130 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> Electronic information: ❑ List❑ Map-Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES EHD USE ONLY <br /> UNDERGROUND TANK(LIST) Street# Street Name City <br /> • CLEANUP SITE(LOP) 1 COxeWER <br /> OTHER CLEANUP SITE INON-LDP) 1 I �Vl IA IA O. <br /> HALwoous WASTE II Y l I Ki OUR, <br /> TIERED PERMITTED FACur, 7 •' ,� <br /> ABOVEGROUND TANK 0100 , L(l i.(6�j rLJ4 f PT ) <br /> I <br /> AN <br /> LIST (MONTTORINO I REMOVAL) � CS PWS <br /> AURDELZ RERGI.2 �r1 AM }j (, I'IWRELEASE RE SPONSE VJ +finIPJ Vt/\,WASTE FACILITY I VEHICLE 4 2/�2 // WRIER OU.Nm <br /> (yl FOOD FACILITY. <br /> ❑T POOL I SPA $ITE MrtIWi10N <br /> ❑DAIRY 5 •• e-lPt.,,J <br /> LAND USE APPLICATION SITES 104- " /JJ U f Ty*/ O �� <br /> ❑SEPTIC PUMPER TRUCK/ t 't2 1//J' 0 HOULxO <br /> y,YMDICHEMKAL TD6ET5 p 1r f f/I. ✓�.. <br /> rp WASTEWATER TREATMENT PLANT OUPA <br /> T❑^HOUSING ABATEMENT T <br /> ❑MOTEtIHDTEL <br /> M ')v�I ur' f7t. <br /> CHICKEN RWCH I DOG KENNEL COPA-HAZ-MAT <br /> e <br /> MEDICAL WASTE FAEUNY I f li l,)Lie) i <br /> ❑TATTOO/BODY PIERCING •J�/ I/ lJ L/ (Srsow W. <br /> OWASTE TIRE p L70 �• LIQ I <br /> "' <br /> ���111''''''111 CGMPUINT <br /> OTHER(PLEASE SPECIFY): [3 ACCCUM,wc <br /> 10 <br /> —BOXE EAI-EHD USE ONLY-* <br /> • <br /> CT Records pre4ded by Staff-PPR Complete. staff Name: <br /> END",06 <br />