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DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue:Stockton, CA 95205-6232 <br /> 6 Telephone: (209)468-3420 l=ax: (209)464-0138 Web: www.sjgov.orglehd � <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: J, GN �bepi -{TUC <br /> I BUSINESS/AGENCY: � <br /> ADDRESS: QZ � -{-fr_cu,�_ C/ LK)!5� CITY/STATEIZIP: �.:nc c ' 10;A <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 $125 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT zrtti-1j��� � DATE <br /> Electronic Information: ❑ List❑ Map–Description%/ <br /> FILE ADDRESS EHD USE ONLY <br /> Street# Street Name CityX FL]Unit 1 <br /> 1. r — <br /> f II ,G .gym_ <br /> 2. �U – (— '�. a4 1 I <<�! \`�10 <br /> 4 Unit 2 <br /> 3.4. < < � °� <br /> EUnit 3 <br /> 6. I]Unit 4 <br /> 8' \-- —f �� Ll ❑Unit 5 <br /> 9. <br /> 10. / <br /> Unit 6 <br /> Specific Date Range of Information Requested: From to / <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> Q UNDERGROUNDTANK(UST)CLEANUP SITE(LOP) MEDICAL WASTE FACILITY SOLID WASTE FACILITYIVEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) HOUSING ABATEMENT M WASTE TIRE <br /> (UNDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY DAIRY <br /> ABOVEGROUND TANK ❑CHICKEN RANCH/DOG KENNEL WASTEWATER TREATMENT PLANT <br /> Q HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL PUMPER TRUCKIYARDICHEMICALTOILETs <br /> ❑TIERED PERMITTED FACILITY ❑POOLISPA LAND USE APPLICATION SITES <br /> ❑TATTOOIBODY PIERCING [ 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 END 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$125 deposit prior to review. ***BOXED AREA-EHD USE ONLY* <br /> )I f C). 1 1 )'S f ���Q� `# /�� 2/1icl /A)0" <br /> 12ry r. A z7VA. <br /> 0 Records provided by Staff-PPR Complete.Staff Name. <br /> EHD 48-06 <br /> 4!28/14 <br />