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DATE RECEIVED EHD LOG NUMBER <br /> FEN OAQUI COUNTY <br /> N ON ENTAL HEALTH DEPARTAT <br /> Z =� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> NOV 2011 Telephone: (209) 468-3420 Fax: (209) 464-0138Web: www.sjgov.org/ehd <br /> RVIRONMENTALLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: �/°.r»,a'y=` r'i��,%C7 BUSINESS/AGENCY: <br /> ADDRESS: = _O tt ' <, STN v ��� . CITY/STATE/ZIP: CP 11,47co <br /> PHONE (1): <_-ta- pyo- 3�3-�I PHONE (2): 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 EE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE t i- ?-7)- ISElectronic Information: ❑ List❑ Map-,,—Description: <br /> FILE ADDRESS <br /> Street# Street Name City EHD USE ONLY <br /> f <br /> 2' t--.f n i r i ❑ Unit 1 <br /> 3. <br /> ❑ Unit 2 <br /> 4. <br /> ❑Unit 2H <br /> 5. .6 <br /> a nit 3 <br /> ❑ Unit 4 <br /> S• ❑SITE MITIGATION <br /> 9. <br /> 10. <br /> ® nit 5 <br /> Specific Date Range of Information Requested: From J� toi <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ]MEDICAL WASTE FACILITY SOLID WASTE FACILITYIVEHICLE <br /> ❑OTHER CLEANUP SITE(NON•LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> P-JUNDERGROUNDTANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> F11ABOVEGROUNDTANK ❑CHICKEN RANCHI DOG KENNEL M WASTEWATER TREATMENT PLANT <br /> I❑HAZARDOUS WASTE/HAZARDOUS MATERIALS ❑MOTELIHOTEL M PLIMPER TRUCKIYARD/CHEMICAL TOILETC <br /> TIERED PERMITTED FACILITY ❑POOLISPA ��,- °LAND USE APPLICATION SITES <br /> { TATTOO/BODY PIERCING COMPLAINTIRESPONSE RECORDS 'il lOTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(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 require a$130 deposit prior to review. **"BOXED AREA-EHD USE ONLY*** <br /> Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 48-06 7/1/15 <br />