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Dr lVE SAN JOAQUIi�k COUNTYEHD LOG NUMBER <br />�, ENVfRONrOENTAL HEALTH DEPARTMENT ✓ <br />SLP 2 6 2016 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Vt/eb: tvww.sjgov.org/ehd <br />ENV1R0UENTALHEALTH PUBLIC RECORDS RELEASE APPLICATION <br />tiPPLiCANT:5--r -- � L - BUSINESS/AGENCY: <br />,ADDRESS: ICU 'a02 CITY/STATE/%IP: L-� l�v,� v <br />RHOI�.E (1): 0,.U'q C•�c7�' —D l � PHONE (2): FAX OR E-MAIL:L� <br />Please <br />IG business day.z t rom date oft appr ie <br />cation submittal for the records to be available. <br />Staff wiii contact you to arrange an appointment date and time to rev!ew the requested records. <br />❑ CHECK BOX TO EXPEDITE QUEST - $1 FEE POOR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />ClG« A�TURE OF r.PrLICAN TA DATE <br />1. List up to ten addresses in the space below, Select the of files from the fist below by checking Ke ap ropriate <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 rive business days for revievit. Appointments <br />should be scheduled accordingly. <br />4. Any f ile.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 $139 deposit prior to review. <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY €:00 AM -5:00P€0 (EXCLUDING HOLIDAYS) <br />EicL;L UniC fri OrBiaiiOR: ❑ List ❑ Nliap — Description: �. <br />Specific Date Range of Information Requested: From to E <br />ENVIRONMENTAL <br />SI TE MITIGATION <br />0 <br />HEALTH DEPARTMENT <br />F6 P" C 15[D�Dbn�E.5S <br />EHD I; fzaE Y <br />FILES <br />) SEPTIC PUMPER TRUCK /5/HOUSING <br />�� �� ��� � <br />0, EN' <br />UNDERGROUND TANK (UST) •reet ti• Street Name City <br />I v�L <br />CLEANUP SITE (LOP) - q I + ( .�) �igqv�?A <br />' 1-- ' , n!�CONSUMER <br />OTHER CLEANUP SITE (NON -LOP) 7 ' 1 J C� <br />W <br />,M7111�'� % , / /1'v`O�/T <br />111 �' if / ` V uJDAIJRY <br />HAZARDOUS WASTE <br />CUPA <br />TIERED PERMITTED FACILITY <br />ABOVEGROUND TANK <br />MOTEL/HOTEL <br />PWS <br />UST (MONITORING / REMOVAL) <br />CUPA-UST <br />HAZARDOUS MATERIALS 3 <br />B <br />MEDICAL WASTE FACILITY <br />SPILL/RELEASE RESPONSE <br />TATTOO/BODY PIERCING <br />WASTE TIRE y <br />SOLID WASTE FACILITY / VEHICLE 4 <br />SOLID WASTE <br />WATER QUALITY <br />FOOD FACILITY <br />POOL / SPA <br />DAIRY 5� <br />SI TE MITIGATION <br />0 <br />( <br />LAND USE APPLICATION SRES <br />) SEPTIC PUMPER TRUCK /5/HOUSING <br />6 <br />YARD / CHEMICAL TOILETS <br />WASTEWATER TREATMENT PLANT <br />CUPA <br />HOUSING ABATEMENT 7 <br />MOTEL/HOTEL <br />- <br />CUPA-UST <br />CHICKEN RANCH / DOG KENNEL <br />B <br />MEDICAL WASTE FACILITY <br />TATTOO/BODY PIERCING <br />WASTE TIRE y <br />SOLID WASTE <br />COMPLAINT <br />OTHER(PLEASE SPECIFY): <br />EI ACCOUNTING <br />70 <br />"'BOXED AREA - EHD USE ONLY" <br />