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08/31/2015 1 : 49: 24 PM -0500 FAXCOM PAU11 Z ur <br /> EIf0 LGG NUMBER <br /> DATE RECEIVEDSAN JOAQUIN COUNTY ar— <br /> REQ �'�;;:�NED ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,CA 85205-6232 i <br /> AUG 311 ZQJ15Telepttone:(209)468-3420 Fax-,(208)464-0138 Veb.%Aww.sjgov.oM1ehd <br /> PUBLIC P?ECORDS RELEASE APPLICATION' <br /> EW � 11Wi imp -- -- -- <br /> C1T4'/3TATEJZiP: 5.2 c..�e'/d�I�.y1 �.V• <br /> ADDRESS:PHONE(l): S— ��,. �;3�5` �1:lti� WEW. +k1 (-0 OACSiMILE: (Vl"+ <br /> vl, , <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to arran n appotntm nt d e and time to review the requested records. <br /> ❑CHECK BOX TO EXPEDITE RE 130 FEE(CA R K ONL 1 REQUEST PROCESSED Ifs 3 B 1111 DAYS <br /> SIGNATURE OF A,PPLICA N T_ �1'� 'L ) >'/ t_ DATE o'�`�31 f t <br /> EFectronlc information: 7ist❑Map-Des/ription: f <br /> FILE ADDRESS EKD USE ONLY I <br /> Street 0 8treei name ' City Unit 4 <br /> f <br /> 4. nit 3 iJ i <br /> 5• _ �_ .l'WE!WTIGATION V <br /> 6. 0 Unit4 <br /> 7. <br /> 10. --+ ❑unit 6 <br /> Specific Dete Range of infa:matian Requested: From to I <br /> EfR RONMENTAL HEALTH DEIsARTf.ENT FILES � <br /> [1 UNDERGRoum TANK(UST)CLEAWP SITF(LOP) ❑MEDICAL WASTE FACILITY El SOLID WRSTE FAGILIfYIVEftICLE <br /> g OTHER CLEANUP SITE(NON"LOP) ❑HoustiiGAGATEMENT Q WASTE TfrtE i <br /> ❑UNDERGROUND TANK(MORITORINGiREFADIIAL) FOOD FACILITY ❑DAIRY <br /> ❑ABovEGPOUND TANK E]CHICKEN RANCH <br /> DOG KENNEL E]WASTEWATER TREATMENT PLANT <br /> ftAZARDous WASTdtfALARDOUS MATERIALS ❑MOTE040TEL ll PUFRPER TwcKIyAWC3EhffCALTo1LETS <br /> 17ITIERED PERtA H0 FACILITY ❑POOLISPA ❑LAND Us[APPLKSATIoN S[TEs j <br /> ❑TAt-r00I$ODY PiERCWG ❑COMPLAINTiRESPONSE•RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PEEWIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRinAy 8:00 Ali-5:00PM(EY•CLUDIN(3 HOLIDAYS)_ l <br /> i. 1_10 iio to ten sddr", mg_in the space shove. Selset the type(R)of Mat from the fist above by cheokinn the approprla.te <br /> 1 <br /> box(es). At least one file type MUST be selected. FaN to(20S)464-0136 or mail to the address Indicated above.- A.ddrot a I <br /> ranges will not be accsptod.ApplIcatiort9 recelved after 3:00 pm will be processed the next buslne6s day. <br /> 2. Far assistance In identifying the nature and content of EHD records,please contact SHD at the number noted above. l <br /> 3. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed appraximataly ten(10) <br /> days after receipt of application. The files will be hold for a maximum of five business days for revlew. Appolrrtments <br /> should be schedufed accordingly. <br /> 4. Any file not returned In the same conditlon as released will be reorganized by END staff at the expense of the applicant I <br /> Future file reviews by the same applicant may require a$126 deposit prior to review, —BOKEA AREA-EHD USE ONLY— <br /> _ <br /> ❑ Records provided by Staff-PPR Complete. staff Name: — I <br /> ruiYne <br /> EfiD <br /> °ceived Time Aug, 31. 2015 11 :48AM No. 9444 <br />