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DATE RECEIVED EHD LOG NUMBER <br /> - — SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT i <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: flL . <br /> COPPUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: Am,1 l �1 IBUSINESS/AGENCY: <br /> ADDRESS: �i' �`-% i^,, ," ot, t, !-( CITY/STATE/ZIP: rcr�i-?^,•cv'�i:f I4- - -1 . <br /> PHONE (f):�(l �'% _ ZCv PHONE (2): FAX ORE-ft�AfL: <br /> Please a�iow 40 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 .15; ` 'C� � DATE <br /> Electronic information: ❑ List❑ r0ap-Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street# Street Name City <br /> Unit 1 <br /> 3- �J Unit 2 <br /> 4. nit 2H <br /> 5- ©'Unit 3 i I <br /> 6. 2-Unit 3HM <br /> 7. <br /> nit 4 <br /> 8' D aITE MITIGATION <br /> �1*15 q_ <br /> 9. <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> [UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MOTELIHOTEL ❑SOLID WASTE FACILITYIVEHICLE <br /> QOTHER CLEANUP SITE(NON-LOP) 9-11OUSING ABATEMENT ❑FOOD FACILITY <br /> DINDERGROUND TANK(MONITORINGIREMOVAL) R(%ASTE TIRE ❑DAIRY,POOLISSPA <br /> ABOVEGROUND TANK ❑CHICKEN RANCHI DOG KENNEL RWASTEWATER TREATMENT PLANT <br /> N'HAZARDOUS WASTE ❑MEDICAL WASTE FACILITY ❑PUMPER 1TRUCKIYARDICHEMiCAL TOILETS <br /> AZARDOUS MATERIALS ❑TATTOO/BODY PIERCING ❑LAND USE APPLICATION SITES <br /> ❑TIERED PERMITTED FACILITY ❑COMPLAINTIRESPONSE RECORDS ®OTHER(PLEASE SPECIFY)�yl� <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List up 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 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 /> ***BOXED AREA-EHD USE ONLY*** <br /> 11 Records provided by Staff-PPR Complete. Staff Name: <br />