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• <br /> DATE RECEIVED SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> v't 7/L,�((�. ✓IRONMENTAL HEALTH DEPARTMENT <br /> l` <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 ' <br /> /Z'�•t'1'' ' '� G� 7 Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd 4 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> ',PPLICANT: ) ss -. /� BUSINESS/AGENCY: f n <br /> -ADDRESS: CITY/STATE/ZIP: <br /> PHONE(1): 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 EXPEDITE REQUEST-$130 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT is ((r j(u c (';% ,1.�,1�, fs�jF ,t� DATE <br /> 1. List up to ten addresses in the`space below. 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(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. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: RIONDAY-FRIDAY 8:00 AM-5:OOPM (EXCLUDING HOLIDAYS) <br /> Electronic information: ❑ List ❑ Map— Description: <br /> ` Specific Date Range of Information Requested: From 4-� _ I ,�,f „ , to 5e-e %2C, <br /> I ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES HD USE ONLY <br /> ❑UNDERGROUND TANK(UST) Street# Street Name City <br /> CLEANUP SITE(LOP) /l —/(LJ►I)(��j ❑CONSUMER <br /> OTHER CLEANUP SITE(NON-LOP) - J7 C'1^i l�5 �tU.-( ��E. /,1i1 G� ,,q►'"fT n/1�. y O� <br /> --p�-k ARDOUS WASTE W 1 vl ✓ l./�1. ❑5'DAIRY <br /> TIERED PERMITTED FACILITY 2 N <br /> `ABOVEGROUND TANKr;a <br /> _UST (MONITORING/REMOVAL) ❑PWS f <br /> HAZARDOUS MATERIALS 3 <br /> �` V V'• /•'`�/ ©�O •_— �1 <br /> If <br /> SPILL/RELEASE RESPONSE <br /> V <br /> 4 � ❑WATER QUALITY <br /> SOLID WASTE FACILITY/VEHICLE <br /> ASI- XD�13� 11— fo„ de 0/6/10 �0l <br /> FOOD FACILITY <br /> POOL/SPA ❑SITE MITIGATION <br /> DAIRY 6 <br /> LAND USE APPLICATION SITES <br /> SEPTIC PUMPER TRUCK/ 6 _ E]HOUSING <br /> YARD/CHEMICAL TOILETS / <br /> WASTEWATER TREATMENT PLANT [gCUPA <br /> ❑HOUSING ABATEMENT 7 <br /> ❑MOTEL/HOTEL <br /> CHICKEN RANCH/DOG KENNEL CUPA- 0 G <br /> 8 --_ <br /> F-1 MEDICAL WASTE FACILITY _ <br /> TATTOO/BODY PIERCING ❑SOLID WASTE <br /> WASTE TIRE B <br /> COMPLAINT <br /> OTHER(PLEASE SPECIFY): ❑ACCOUNTING <br /> 10 <br /> ­BOXED AREA-EHD USE ONLY <br /> ti ^, I.Cf Jr• I k I i !/ / % f V t r , r %I' <(.,?l A /C�.�-K l= (r3 t t(/ ?I S•c_ <br /> s l <br /> &k4 S r�— --i'! pr1- <br /> 4 /,n — — V <br /> ❑ Records provided by Staff-PPR Complete. Starr Name. + n r T ' JA f 0 <br /> EHD48-06f,lI(( Mil c 'W 7FM V+ AQIJ iC&(71 , kw ' <br />