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DATE RECEIVED EHD LOG NUMBER <br /> SAN .IOAQUIN COUNTY <br /> VV ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 DD EE <br /> SEP 0 8 2015Tefephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br /> E�,t„a „Np„R/�Sg�EEp41I�( ESR, �„ PUBLIC RECORDS RELEASE APPLICATION <br /> PE <br /> APPLIC�NT: (V{�i C C�I��1I�zr�ty('� BUSINESS/AGENCY: 011(2i7 <br /> ADDRESS: CITY/STATE/�ZInP: <br /> PHONE (1):(�Z�] ��102 PHONE (2): �FACSIMI E <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 <br /> Electronic Information: ❑ List❑ Map—Description: <br /> FILE ADDRESS <br /> Street# Street Name City EHD USE ONLY <br /> 1. �� /"�-jj1 A' 111 L ems_ <br /> 2. i� - IVIL �t T� ILoe_ ❑Unit 1 <br /> 8. l�00 GJ 1,1,4��P/�yyt���C kw L <br /> 4. arI - /00 ei, I'��Nl,�'-�'l ❑ Unit 2H <br /> r7. <br /> g1ty <br /> L✓Unit3 <br /> Lri Unit 4 <br /> �� <br /> MSITE MITIGATION <br /> 9. <br /> 10. <br /> ❑ nits <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 FACILITYNEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑FOOD FACILITY <br /> ©ABOVEGROUND TANK ❑DAIRY <br /> ' <br /> ❑CHICKEN RANCH/DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> ❑HAZARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTELIHOTEL ❑PUMPER TRUCKIYARDICHEMICALTOILETS <br /> TIERED PERMITTED FACILITY ❑POOLISPA ®LAND USE APPLICATION SITES <br /> ❑TATTOOIBODY PIERCING 4COMPLAINTIRESPONSE 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 un 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 /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 46-06 <br /> 7HH5 <br />