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DATE RECEIVED EHD LOG NUMBER <br /> -- SAN JOAQUIN COUNTY <br /> E%.,-,'ONMENTAL HEALTH DEPARTNir-AT � <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> NOIR 2 2101:) Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehdj <br /> OIRONIAENTAL PUBLIC RECORDS RELEASE APPLICATION <br /> e n <br /> APPLICANT: BUSINESS/AGENCY: V S <br /> i <br /> ADDRESS: ` c�cr—c�, a �s �,, ��.,,�� r-J,; - CITY/STATE/ZIP: CA,°t47co <br /> r� <br /> PHONE (1): PHONE (2): FACSIMILE: <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(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE o- Z3- 15 <br /> Electronic Information: ❑ List ❑ 6' a — Description: <br /> FILE ADDRESS <br /> Street# Street Name City EHD USE ONLY <br /> 1 901 ,i_2 30 0 <br /> 2. 1"o'i 1"o El Unit 1 <br /> 3. <br /> El Unit 2 <br /> 4. <br /> ❑ Unit 2H <br /> 5. <br /> ©'Unit 3 <br /> 7. <br /> ❑ Unit 4 <br /> 8. <br /> ❑ SITE MITIGATION <br /> 9. ;r <br /> 10. <br /> El-Unit 5 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) -,❑MEDICAL WASTE FACILITY { .SOLID WASTE FACILITYIVEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENTI❑WASTE TIRE <br /> ❑UNDERGROUND TANK(MONITORING/REMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ❑HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL PUMPER TRiUCKIYARDICHEMICAL TnILETc <br /> ❑'TIERED PERMITTED FACILITY ❑POOL/SPA ❑iLAND USE APPLICATION SITES <br /> ❑TATTOO/BODY PIERCING 0 COMPLAINT/RESPONSE RECORDS 7 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 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. ***BOXED AREA-EHD USE ONLY*** <br /> q Records provided by Staff-PPR Complete. Staff Name: j-", <br /> EHD 48-06 7/1/15 <br />