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DATE RECEIVED ., EHD LOG NUMBER <br /> . � t k SAN .IOAQUIN COUNTY 'a � <br /> ENVIRONMENTAL HEALTH DEPARTMq1W ` '' ► <br /> DEC 0 2 2015 1868 East Hazelton Avenue, Stockton, CA 9520 232 ' + <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web: www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTI-1 PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESS/AGENCY: , �/ <br /> ADDRESS: 3��$ (�jBS{(ty�_ CA CITY/STATE/ZIP: e(Qo4� ;UU ( tA q�S.z3 <br /> PHONE(1): qZ5--jSj—(p3-?-�7 PHONE(2): 975=a$5-53y3 FAX OR E-MAIL: 13dai-DSdU r►vf°• <br /> Please allow 10 business days from date of application submittal for the records to be avails le. r <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> KCHECK BOX TO EXPEDITE REQUEST-$130 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE 2 2 <br /> Electronic Information: XList ❑ Map—Description: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> Street# Street Name City <br /> 1' oto fl�i Eas+- mipior v-e <br /> 2 ❑unnl <br /> aaos .rA•h r q � _ LOP 4 �e `��s-�o <br /> 3. 312-S vt a /Tv IL>�_ 1-0 P a-�y/ ❑Unit 2 <br /> 4. 3lo l LOP E peptYy -co ❑Unit 2H <br /> 5. raq t k {E". � l.�r- (� f�Unit 3 'J <br /> 6. p.$�t 'r1 S Sb <br /> ��- �� Unit 3HM <br /> 7. <br /> (l7v 1Ltula ntt a <br /> 8. <br /> O�,t^­l E3 SITE MITIGATION <br /> 10 CI unit 5 <br /> Specific Date Range of Information Requested: From I4 7D to 20 19- <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ®UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑MOTELIHOTEL ❑SOLID WASTE FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑FOOD FACILITY <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑WASTE TIRE ❑DAIRY,POOLISPA <br /> ®ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ®HAZARDOUS WASTE ❑MEDICAL WASTE FACILITY ❑PUMPER TRUCKIYARDICHEMICAL 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 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 /> 0 Records provided by Staff-PPR Complete. Staff Name: <br />