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DATE RECEIVED EHD LOG NUMBER <br /> SANJOAQUIN-C—OUN-T-Y <br /> ENVIrcONMENTAL HEALTH DEPARTNI,-NT <br /> 0( l ��)� 1 68 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> `Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> iV1 ERM[ [SERVONMENTAL CF7.5HEAU LIC RECO DS RELEASE APPLICATION <br /> PF MITISF�IVIG `" <br /> Sqac[ 6- *G hq4 <br /> APPLICANT: ct )1c%14A BUSINESS/AGENCY: <br /> ADDRESS: L CITY/STATE/ZIP: } �c�k ,4 �4. g 1;t-L (o <br /> PHONE (1): 1 - PHONE (2): 2-o cl _q C) FACSIMILE: <br /> TENTATWE*APPOIN MENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal-"Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-"FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICAN S - DATE <br /> Electronic Information: ❑ Li t❑ Map—Description: <br /> FI E ADDRESS EHD USE ONLY <br /> JL Street# treet Name city ❑ Unit 1 <br /> Ill 1. ( 90 1 �l, o rz v 5-k S�ot�l�}v� � � � � 5 , C4 <br /> �" 2. ❑Unit 2 <br /> 3. <br /> 4. —❑ Unit 3 <br /> 5. )�. <br /> 6. nit 4 <br /> 7. <br /> 8. ❑ Unit 5 <br /> 9. <br /> 10 ❑ Unit s <br /> JH1' <br /> ic D 'Range of Information Re uested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> �ER�ROUND TANK(UST)CLEANUP ITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE.FACI IT [VEHICLE <br /> CLEANUPSITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRESXhb'e 1/rAPI�Z, <br /> ERGROUND TANK(MONITORING/RE OVAL)�C ❑FOOD FACILITY ❑DAIRYVEGROUND TANK ❑CHICKEN RANCH]DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> AZARDOUSWASTE/HAZARDOUS MATE IALS0�1 ❑MOTEL/HOTEL ❑PUMPER TRUCK[YARDICHEMICALTOILETS <br /> TIERED PERMITTED FACILITY ❑POOL/SPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOO/BODY PIERCING ❑COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECOR S ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List up to ten addTwored <br /> in the pace above. Select the type(s)of files from the list above by checking the appropriate <br /> box(es). At least e type UST be selected. Fax to(209)464-0138 or mail to the address indicated above. Address <br /> ranges will not bted-f additional assistance with file addresses, contact the EHD. Applications received after <br /> 3:00 pm will be ped the ext business day. <br /> 2. The EHD will notipplica t if any EHD files exist. An appointment for review will be confirmed approximately ten (10) <br /> days after receiplicatio . The files will be held for a maximum of five business days for review. Appointments <br /> should be schedcordin ly. <br /> 3. A file that is activng wor ed on by EHD staff may not be immediately available for review. A new application may be <br /> submitted when tis avail ble. <br /> 4. Any file not returned in the sam a 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-AR010EHDUS ;ONL i <br /> .+i- <br /> t,. <br /> i <br /> S �� t-.w?>r�G'� .�� - •r L -..* 9 _ <br /> 5 <br /> J r •2 1. ..- -1 " �+. r ,� - _ 1 .,. 2t y _. K t R:r,..Y i STii�3� �� <br /> ❑ Recor'ds providdf by Sta,- PPR Complete staff Name _ _ > r � , , <br /> r t <br /> EHD 48-06 914112 <br />