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6ACevE IV <br /> L EHD LOG NUMBER <br /> SAN .JOAQUIN COUNTY <br /> MA ' a0'i ENVIRONMENTAL HEALTH DEPARTMENT //5�5 h <br /> 1868 East Hazelton Avenue, Stockton, CA 95MENT32 {/V� �,,/) V <br /> ENvptONMEWA-HEXT" Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> PEIK RAER PUBLIC RECORDS RELEASE APPLICATION/� 1 <br /> APPLICANT: '`?: Sfylt'� BUSINESSIAGENCY: 61)" v1 0 <br /> ADDRESS: CITY/STATE/ZIP: <br /> PHONE(1): C C'1i(p12Z7-1a�3� PHONE(2): FAX ORE-MAIL: a , SPbOO.C'"I"I✓ <br /> Please allow 10 business days from date of application submittal for the records to be availa le. <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$139 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT /y t/2S�Cl� SIG' �tibVle DATE 1G J'-'- <br /> 1. List up to ten addresses in the s�ce below. Select t e type(s) of files from the list below by checkin 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$139 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(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(UST) Street# Street Name city <br /> } CLEANUP SITE(LOP) � CONSUMER (] <br /> n" <br /> F]OTHER CLEANUP SITE(NON-LOP) �� � � ��y,)1''1 �• �)'V— �C� I <br /> ❑HAZARDOUS WASTE (\ DAIRY <br /> ❑TIERED PERMITTED FACILRY 2 D� • U`V G�At�+� <br /> ❑ABOVEGROUND TANK ` \ PWS <br /> [—]UST (MONITORING/REMOVAL) L <br /> ❑HAZARDOUS MATERIALS 3 <br /> ❑SPILLLRELEASE RESPONSE \\^ \ <br /> WATER DUPLN <br /> ❑SOLID WASTE FACILITY/VEHICLE 4 �U V <br /> ❑FOOD FACILITY �` <br /> ❑POOL/SPA I, SiE MmOanoN <br /> ❑DAIRY 5 v <br /> ❑LAND USE APPLICATION SITES <br /> ❑ HORSING <br /> SEPTIC PUMPER TRUCK/ <br /> 6 <br /> YARD/CHEMICAL TOILETS <br /> ❑WASTEWATER TREATMENT PLANT CUPA <br /> ❑HOUSING ABATEMENT l <br /> ❑MOTELMOTEL <br /> ❑CHICKEN RANCH/DOG KENNEL CUPA-UST <br /> ❑MEDICAL WASTE FACILITY 8 <br /> ❑TATTOO/BODY PIERCING <br /> SCUD WASTE <br /> F1 TIRE <br /> 9 <br /> ❑COMPLAINT <br /> ❑OTHER(PLEASE SPECIFY): AC Uo . <br /> 10 <br /> —BOXED AREA-EHD USE ONLY— <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> ` EHD 48-06 <br />