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FI'om: Erik Brown Fax:(888)828-2635 To: 12094640138@rcfax.ec Fax: (200)464-0138 Page 2 of 2 01104r2018 B:21 AM <br /> N <br /> AMA ( RECEIVf� moaDepartment <br /> —'—C.0,;LI N Tv_.,_.._ UBLIC RECORDS RELEASE APPLICATION <br /> .IAN 0 4 2098 � <br /> w, +�ENVIRONMENT EHD LOG NUMBER: <br /> APPLICANT: '�, ,... 51 <br /> (SERVICES 13USINESSIAGENCY: <br /> ADDRESS: <br /> (1) CITYISTATE/ZIP: (,p3gs�-I- F-Frfl '7 <br /> PHONE(1}: 2.fs�- Q,( Df PHONE (2);c�7.Y'� o y ',�'j - FAX OR E-MAIL: ! <br /> Please allow 10 business days from date of application submittal for the records to be available <br /> Staff will contact you to arran n point e t date and time to review the requested records, <br /> SIGNATURE OF APPLICANT t �r"' .�'^-'`', DATE <br /> 1. List uo to ten addresses i , n space ogtow:�"Addregs 'es WILL NOT be accepted. Select the type(s)of files from th <br /> list below by checking the appropriate box(es). At least one file type MUST be selected. Fax to(2091454-013a mail to the <br /> address indicated below, or email to info(�sicehd 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. ' <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-5:00PM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List Map— Description: <br /> Specific Date Range of information Requested: From to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES (Specific addresses only,address ranges will not be accepted) EHD <br /> tom® U E ONLY <br /> Underground Tank(UST) Street— Street Name <br /> City <br /> Cleanup Site(LOP) ' <br /> L)�Olher Cleanup Site(Nan-LOP) V �g[.six P � d1 occtisu an AD <br /> 1 Al <br /> Hazardous waste <br /> Tiered Permitted Facilil f punr <br /> MAbovegmund Tank y Z ���� �� �"'�( /'SC � ❑ <br /> NtUBT (Monitoring/Removal) 5 ` <br /> Hazardous Materials ❑vws <br /> (.Spill/Release Response <br /> ❑Solid Waste Facility/Vehicle 4 nrcx Ouam <br /> ❑Food Facility <br /> ❑Pool/Spa -- — <br /> ❑Dairy b ire Mmcauma <br /> F]Land Use Application sites V/t <br /> ❑septic Pumper Truck) <br /> 6 Houswc <br /> Yard 1 Chemical Toilets <br /> ❑Wastewater Treatment Plant Irl`I <br /> ❑Housing Abatement r DUPA <br /> ❑M-1-1motel AST/HM/Hw <br /> ❑Chicken Ranch/Dog Kennel <br /> F-1medicalWaste Facility 6 UPA <br /> F1TattodBo0 Piercing UST <br /> Waste Tire <br /> y ❑Socio Wnsrs <br /> Complaint <br /> F1 Other(Please specify): <br /> 10 Accourmxo <br /> *`"BOXED AREA-EHD USE ONLY*'^ <br /> -f-O Records provided by Staff-PPR Complete. staff Name: <br /> EIDba-ae <br /> 1868 E- Hazeiton Avenue I Stockton, California 95205 I T 209 468-34201 F 209 464-0138 ( www.SICehd-com <br /> —Received Time—Jan. 4• _2018 8: 15AM No, 2811 <br />