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DAT /`/SEIv IE <br /> ��IYR�mp 1�/((yy SAN.IOAQUIN COUNTY EHD LOG NUMBER <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> APR u ij 20V A, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 own <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> • ENVIRONMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLIC L Q rho v4 2z BUSINESS/AGENCY:Tt-1`C.- iuQTLfS-lp,x G P <br /> ADDRESS: YZy £-Lye-cl—p CITY/STATE/ZIP: Ka/ r s� e4, 4�^3j J <br /> PHONE(1): <br /> "/ 7Z�_ 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 REQU�& 139 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 B SIN S DAYS <br /> SIGNATURE OF APPLICANT �/,ts_7 DATE Zj / 7 <br /> 1. List uo to ten addresses in the space below Select the types)of files from the list below by checking t appropriate <br /> box(es). At least one file type MUST be se cted. 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. 4/1 <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 /> �NDERGROUNDTANK(UST) Street# Street Name City <br /> CLEANUP SITE(LOP) <br /> r 1,,1 <br /> OTHER CLEANUP SITE(NDN-LOP �UO W - �t.}ll C� l�/I1 ' ^ 000NSUMER/^ ^ <br /> HAZARDOUS WASTE J -(Y t'1 l,XI 1•N- IV vA✓/ <br /> YY <br /> TIERED PERMITTED FACILITY 2 El DAIRY <br /> ZASOVEGROUNDTANK <br /> __g UST (MONITORING/REMOVAL) [I PWS <br /> I9 HAZARDOUS MATERIALS S <br /> SPILL/RELEASE RESPONSE <br /> ❑SOLID WASTE FACILITY/VEHICLE 4 ATER QU-1- <br /> ❑FOOD FACILITY <br /> ❑POOL/SPA <br /> DAIRY 5 1 ' SITE MITIGATION <br /> ❑LAND USE APPLICATION SITESOM <br /> - <br /> ❑SEPTIC PUMPER TRUCK/ 6 HOUSING <br /> YARD/CHEMICAL TOILETS <br /> WASTEWATER TREATMENT PLANT <br /> �HOU6ING ABATEMENT 7 CUPA <br /> I]MOTELJHOTEL <br /> ❑CHICKEN RANCH!DOG KENNEL UPA-UST <br /> MEDICAL WASTE FACILITY S <br /> ❑TATTOO/BODY PIERCING <br /> F�WASTE TIRE ❑SOLID WASTE <br /> 9 <br /> 1�9 COMPLAINT <br /> OTHER(PLEASE SPECIFY): <br /> 10 1]ACCOUNTING <br /> "`BOXED AREA-EHD USE ONLY"' <br /> ❑ Records provided by Staff-PPR Complete. Staff Nama: <br /> EHD 48-06 <br />