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RECEIVED <br /> � SAN JOAQUIN COUNTY *USH EHD LOG NUMBER <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> MAR U 9 2011 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> MtO:NMEWAL I-iMTH <br /> F''EMAIT/8EITtCES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: V <br /> 611-L- SA BUSINESS/AGENCY:_/0/Q/92/W-7c <br /> ADDRESS: q5,:10 G•'Cy Gfd <br /> PHONE(1): ;?eO PHONE(2): W4 ,;�. 3� 7709/ FACSIMILE: -2. z? <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 PA91 OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSIN SS DA <br /> SIG ATURE OF APPLICANT DATE <br /> Electronic Information: ❑List Map—Description: <br /> FILE ADDRESS END USE ONLY / <br /> Street# Street Name City r- El Unit 1 <br /> 2. <br /> TEIL;iW;' <br /> Unit <br /> 4' S "17 / V Unit 3 <br /> p ,fie f1rJiS l oP <br /> 7. 4idG s;ti'1,D Pkv/ ' DT ` ✓C11vW f <br /> 8. J � ENnit 5 <br /> 9. � . <br /> 10. <br /> '� I p ttnTt <br /> Specific Date Range of Information Requested: From to rn I h�Un <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MEDICAL WASTE FACILITY ❑SOLID WASTE FACILTTYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT Q WASTE TIRE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> HAZARDOUS WASTE/HAZARDOUS MATERIALS ❑MOTEL/HOTEL ❑PUMPER TRUCKIYARD/CHEMICAL TOILETS <br /> %TIERED PERMITTED FACILITY ❑POOLISPA ❑LAND USE APPLICATION SITES <br /> ❑TATTOO/BODY PIERCING ❑COMPLAINT/RESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List un 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 flies 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 /> CIO 10-L <br /> g <br /> D Record <br /> provided by Staff-PPR <br /> � Com�p1l�et�e. Staff <br /> �Name: <br /> END 48-06 � s CD �` 449 <br /> " � le-C ' { <br /> (',e,5 -1 <br /> sd-r� U T re:L)� -k; 0,f�Ywr I�,{� : <br />