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'�.��' <br />DATE SAN ..JOAQUIN COUNTY EHD LOG NUMBER <br />MAA o, 9 2016 ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232' <br />T 1 phone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />1 P�VIRONi EI�4i 6fEF1l. <br />GES PUBLIC RECORDS RELEASE APPLICATION <br />4'-- PPUCANT: Qii ��1 �`1s BUSINESS/AGENCY: QX i ACirl,�"�s� 1G <br /><<,,s DDRESS: I�,7 Ifo, !� <br />R4 I , , ( CITY/STATE/ZIP: /;d1 1�1��� L t22 <br />PHONE (1): OD PHONE (2): Ij[� q0-1— FAX OR E-MiAIL: CAWPh� (E?. l'b*ck(f <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 ON - REQUEST PROCESSED IN 3/BUSINESS DAYS <br />SIGNATURE OF APPLICANT �OiAf C')i ' DATE <br />1. List up to ten addresses in the space below. Select the type(s) of files from the list below 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 cond'tion as released will be reorganized by EHD staff at the expense of the applicant. <br />Future fiie.reviews by the same applicant may require a $130 deposit prior.to review. <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:00PM (EXCLUDING HOLIDAYS) <br />Electronic Information: ❑ List ❑ Map — Description: � <br />Specific Date Range of Information Requested: From <br />to <br />ENVIRONMENTAL <br />� <br />HEALTH DLESRTMENT <br />FILE ADDRESEHDS <br />USEONLY <br />[a UNDERGROUND TANK (UST) <br />Street # <br />Street Name <br />City <br />CLEANUP SITE (LOP) <br />OTHER CLEANUP SITE (NON -LOP <br />/% <br />CONSUMER .!. <br />/1 e�y�( <br />+� HAZARDOUS WASTE <br />y <br />❑ DAIRY <br />TIERED PERMITTED FACILITY <br />Z <br />- <br />ABOVEGROUND TANK <br />I ❑ PWS <br />i <br />i UST (MONITOP.ING / REMOVAL) <br />T® HAZARDOUS MATERIALS <br />SPILL/RELEASE RESPONSE <br />/ <br />,�,/ <br />Ly WATER QUALITY <br />❑ SOLID WASTE FACILITY / VEHICLE <br />4 <br />FOOD FACILITY <br />POOL / SPA <br />E(SITE MITIGATION <br />❑ DAIRY <br />6 <br />`%�p/1 / 1 <br />E] LAND USE APPLICATION SITES <br />PUMPER TRUCK / <br />YARD / CHEMICAL TOILETS <br />6 <br />❑ HOUSING <br />WASTEWATER TREATMENT PLANT <br />Ej/CUPA <br />HOUSING ABATEMENT <br />7 <br />' <br />MOTEUHOTEL <br />❑ CHICKEN RANCH / DOG KENNEL <br />MEDICAL WASTE FACILITY <br />i <br />8 <br />_ <br />[q'CUPA - HAZ-MAT <br />TATTOO/BODY PIERCING <br />WASTE TIRE <br />g <br />SOLID WASTE <br />COMPLAINT <br />❑ ACCOUNTING <br />OTHER(PLEASE SPECIFY): <br />10 <br />-BOXED AREA - EHD USE ONLY- <br />