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RECEIVED <br />SAN J OA Q U I N JUN 12 zoic Environmental Health Department <br />C O U N T Y LNVIRONMENTAL HEALTH PUBLI RECORDS RELEASE APPLICATION <br />• PERMIVSMA� lbw �M ( 51PI51 <br />IT BY EMAIL `�7 "', J �p <br />EHD LOG NUMBER: �/ <br />APPLICANT: Mj_(4kyl t) 1kJ1N) BUSINESS/AGENCY: TJYY6&Ct L C44fvlfl ✓,n - <br />ADDRESS: SO ��nlclt,,rtl6utd (pU✓-i fV!+t. loo CITYISTATE2IP: SacA,Gt iA9Ag-p (f} 9Y6.74 <br />PHONE(1): (9lla}2llo 50�� PHONE (2): FAXORE-MAIL: K42O.t,�aoc�Cafarrcun. <br />Please allow 10 business days from date of application submittal for the records to be avallable. 1.1im <br />Staff will contact you to arrange an appointment date and time to review the requested records. <br />SIGNATURE OF APPLICANT _� DATE (o-jZ-I $ <br />1. List up to ten addresses in the space below. Ad ress ranges WILL NOT be accepted. Select the type(s) of files from the <br />list below by checking the appropriate box(es). At least one file type MUST be selected. Fax to 1209) 464-0138, mail to the <br />address indicated below. or email to info(dsirehd com. Applications received after 3:00 pm will be processed the next <br />business day. <br />2. For assistance in identifying the nature and content of EHD records, please contact EHD at the number noted below. <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. (0 <br />Future file reviews by the same applicant may require a $152 deposit prior to review. <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:OOPM (EXCLUDING HOLIDAYS) <br />Electronic Information: ❑ List ❑ Map - Description: <br />Specific Date Range of Information Requested: From to <br />• <br />• <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FILES <br />(Specific addresses <br />FILE ADDRESS <br />e <br />only,address ranges will not <br />be accepted) <br />p <br />2 00 <br />EHD USE ONLY <br />-- � <br />RUnderground Tank (UST) <br />Street # <br />Street Name <br />City <br />e <br />I D o 7 <br />(, k v vLvk .fi-rt c- <br />/'� <br />JT "Lk -'I D•Jt <br />Cleanup Site (LOP)`� <br />® Other Cleanup Site (Non LOP) <br />- - ❑ Goaswea <br />H82ard011s waste <br />❑ Tiered Permitted Facility <br />R Aboveground Tank <br />Y <br />I D <br />E C(1 Vr l ff rt e r <br />I'•t/'1 <br />J a tM t�✓t <br />� [3 Dray <br />y (y `` 1 <br />NFA <br />❑ PWS <br />OUST (Monitoring / Removal) <br />0 Hazardous Matenals <br />t <br />I o3 Q <br />E , LYIVVCL� Joy- c.* <br />la Spill / Release Response <br />® Solid Waste Facility / Vehicle <br />r-1 Food Facility <br />4 <br />I D D I <br />E . �tA�etran pv.e.,nv-L <br />,S-YoLu.d'o✓t <br />♦rta Oiu n <br />SrrE MmogwH <br />❑ Pool / Spa <br />❑Dairy i <br />S <br />102Y <br />�, f fwira✓L AvenV— <br />J4 -0a -'tDA <br />❑ Land Use Application Sites <br />❑ Septic Pumper Truck I <br />Yard / Chemical Toilets <br />S <br />I D D Z <br />rr n�� <br />G • wt ✓rt,l/l .ftYlR r <br />�� <br />f -I'0 L,ssa o✓L <br />Q Houswp <br />Wastewater Treatment Plant <br />ecUPA <br />❑ Housing Abatement <br />F1MoteMotel <br />T <br />iooU <br />r Uw-a V <br />AST/HM/y <br />° <br />lolls j iD <br />E • �kOVA J' I yc-e-f <br />StDCUA-DA <br />UPA <br />❑ Chicken Ranch I Dog KennelUST ® <br />Medical Waste Facility <br />ry <br />❑ TanooMody Piercing <br />Waste The <br />Complaint <br />8 <br />i014 <br />r l.�l/�./t�L. UjynnLlMa <br />�r'l <br />10 <br />lot`j <br />�. C1nJ✓Lln .f'}✓Wr <br />,1+g(.u�vVl <br />❑ Acc..e e <br />Other (Please Specify): <br />"'BOXED AREA - EHD USE ONLY*** <br />Wli —11 s tl r" ✓rt /eLL <br />❑ Records provided by Staff -PPR Complete. Staff Name: Eno 43-06 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />