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DATE RECEIVED EHD LOG NUMBER <br /> \� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> C <br /> 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: =1 tP� ' S� t2cU I <br /> 1/1 k 6 - U / BUSINESS/AGENCY:�� <br /> ADDRESS: J ✓l ' IJ CITY/STATE/ZIP: ICA <br /> PHONE(1): �/— �%- '��zJ PHONE(2): FACSIMILE: <br /> s. <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 REQUE�125FE OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUST ESS D Ys <br /> SIGNATURE OF APPLICANT DATE 7q <br /> Electronic Information: ❑ List❑ Map—Description: 71 <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name city I]Unit 1 <br /> 2. 71?"'C'ty f" C� � ��� I I �Unit2 �1 <br /> 3. (. '1 <br /> 4. OA t <br /> nit 3 <br /> 5. / <br /> 6. /�/ t�( nit 4 <br /> 7. <br /> 8. <br /> ❑Unit 5 <br /> 9. <br /> 10. <br /> ❑Unit 6 <br /> Specific Date Range of Information Requested: From SFS to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> Q UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILITYNEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑F000 FACILITY ❑DAIRY <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCHI DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ❑HAZARDOUS WASTE/HAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARD/CHEMICAL TOILETS <br /> ❑TIERED PERMITTED FACILITY ❑POOUSPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOOIBODY 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 un 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 END 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$125 deposit prior to review. ***BOXED AREA-EHD USE ONLY*** <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 48-06 4128114 <br />