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R Y E® BER <br />SAN JOAQUIN COUNTY O <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />JUN 2 4 2014 1868 East Hazelton Avenue, Stockton, CA 05205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.org/ehd <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: KS, VI-/ A//b, v, `' TI<A BUSINESS/AGENCYA/C- 8 <br />* I �T/ f CADDRESS: , jfjLgCITY/STATE/ZIP: <br />PHONE (1): %Zs -�Cp7' fz i_? 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 CP CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIG1A1 U.- OF APPLICANT � � % DATE 4 f jai f< <br />IElectronic Information: ❑ List ❑ Map — Description: <br />FILE ADDRESS <br />EHD USE ONLY <br />❑ Unit 1 <br />Q Unit 2 <br />Street # <br />Street Name <br />City <br />2. <br />20 2-S <br />7-�Li <br />3. <br />. E]Unit 3 <br />4. <br />5. <br />-jJ Un�it4 <br />6. <br />7. <br />❑ Unit 5 <br />8. <br />9. <br />❑ Unit 6 <br />10. <br />3 <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL HEALTH DEPARTMENT_ FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ MEDICAL WASTE FACILITY <br />Cx1 SOLID WASTE FACILITYNEHICLE <br />OTHER CLEANUP SITE (NON -LOP) ❑ HOUSING WASTE <br />TIRE yl <br />UNDERGROUND TANK (MONITORINGIREMOVAL)i ❑ FOOD FACILITY ❑ DAIRY 'N" <br />C ABOVEGROUND TANK ❑ CHICKEN RANCH/ DOG KENNEL ❑ WASTEWATER TREATMENT PLANT <br />WHAZARDOUS WASTEMAZARDOUS MATERIALS ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARDICHEMICALTOILETS t <br />❑ TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br />❑ TATTOO/BODY PIERCING COMPLAINT/RESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:OOPM (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 (2 9) 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 $125 deposit prior to review. ***BOXED AREA - EHD USE ONLY*** <br />untkit Ccs S i u` t`� o <br />❑ Records provided by Staff -PPR Complete. Staff Name: <br />t=HU 4n-Uti <br />4128/14 <br />