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DATE RECEIVE; c O nO E awi "`�aln iaaFa <br /> j SAN JOAQUIN C(1L00 N WHBb Ol SIOZ 'SZ N l P <br /> r ENVI RONMENTAL HEALTH DEPARTMENT <br /> NOV 2 5. Z015 1868 M st Hazelton Avenue, Stockton, CA 96205-6232 <br /> Telephone: (209) }68-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> til�IPlViRONMENTALHEALTI PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: Ab( �yAh;^ BUSINESS/AGENCY: ✓ 1I US �U1 Vironr th�(i7 t <br /> ADDRESS: 333 0 cA 1ru.1 Pa. I," 4LSU CITYISTATE/ZIP: (�_Xeyu Pr^r'IL, �4 hs(yYZ <br /> PHONE (1): PHONE (2): FAX OR E-MAIL: 930-&76- 61N> <br /> Please allow 10 business d Iys from date of application submittal for the records to be available. adMda)ng e <br /> Staff will contact you to ar ange an appointment date and time to review the requested records. SFra4 u3;rt.n.t <br /> ❑ CHECK BOX TO EXPEDITE R ST 130 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE iIJ1S/ 15" <br /> Electronic Information: ❑ List ❑ Aap—Description: <br /> FILE AC )RESS <br /> EHD USE ONLY <br /> Street Street) lame I City I n n- <br /> �� �s ❑Unit 1 <br /> z. <br /> 3, ❑Unit 2 <br /> [j Unit 2H <br /> S. �� �1n1t3 1 <br /> 6• 11-y—t7 ❑ Unit <br /> 3HM <br /> 7, Ly-u'it 4 <br /> 8, ❑SITE MITIGATION <br /> 9. <br /> ❑ Unit 5 <br /> 10. <br /> Speeife Date RanGe of Information Requested: Fron t911- 11% VS T LUP w: i ANO to 0 Li -1d I S <br /> E gVIRONMENTAL HEALTH DEP RTMENT FILES I <br /> UNDERGROUND TANK(UST)CLEANUP SITE(L )P) ❑MOTELIHOTEL ❑SOLID WASTE FACLITYIVEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑FOOD FACILrrY <br /> UNDERGROUND TANK(MONITORINGIREMOVAL F-1 WASTE TIRE ❑DAIRY,POOUSPA <br /> ❑ABOVEGROUND TANK ❑CHICKEN RANCHI DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ❑HAZARDOUS WASTE ❑MEDICAL WASTE FACILITY ❑PUMPER TRUCKIYARD(CHEMICAL TOILETS <br /> ❑HAZARDOUS MATERIALS ❑TATTOO/BODY PIERCING ❑LAND USE APPLICATION SITES <br /> ❑TIERED PERMITTED FACILITY ❑COMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECOF )S ARE AVAILABLE FOR REVIEW' MONDAY-FRIDAY 8:00 AM-S:OOPM(EXCLUDING HOLIDAYS) <br /> 1. List up to ten addresses in the spat 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.Applin :ions received after 3:00 pm will be processed the next business day. <br /> 2. For assistance in identifying the no ure and content of EHD records,please contact EHD at the number noted above. <br /> 3. The EHD will notify the applicant If r ny EHD files exist. An appointment for review will be confirmed approximately ten(10) <br /> days after receipt of application. Tt )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 cc edition as released will be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviews by the same app cant may require a$130 deposit prior to review. <br /> ­BOXED AREA-EHD USE ONLY"` <br /> L <br /> ■ <br /> ❑ Records provided by Staff-PI R Complete. Staff Name: ■ ■ <br /> i■ <br /> TO/T0 39�d7'J1N34V021IfsN3 Sf11,b1S 90099L90S9 T9:0T 9T0Z/9ZlIT �■ <br />