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RECEIVED <br />DATE RECEIVED SAN JOAQUIN COUNTY EHD LOG NUMBER <br />ISEP 2 7 ENVIRONMENTAL HEALTH DEPARTMENT <br />ENVIRONMENTAL HFEALTH1866 East Hazelton Avenue, Stockton, CA 95205-6232 <br />PERMIT/SERVICES Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd SH(OIJ4 <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: P <br />ADDRESS: <br />BUSINESS/AGENCY: <br />CITY/STATE(ZIP:C-_; 4§. �,=� �� �, Lt <br />PHONE (1): �Li_ % (cs-,Zj� PHONE (2): 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 arrange an appointment date and time to reviewthe requested records. <br />❑ CHECK BOX TO EXPEDITER QUEST - 139 FE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 B INESS AYS <br />SIGNATURE OF APPLICANT DATE C1 _ <br />1. List uo to ten addresses in the space below. elect 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) 464-4138 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 $139 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: <br />Specific Date Range of I <br />ist L_I Map — Description: <br />ation Requested: From ;:� (L3(, f7 <br />to i <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FILE ADDRESSFILES <br />EHD USE ONLY <br />UNDERGROJND TANK (UST) <br />Street ik <br />Street Name <br />City <br />] ^ <br />' <br />Lc'�s).. <br />C)CONS: VIER <br />CLEANUP SITE (LOP) <br />OTHER CLEANUP SITE (NON -LOP) <br />ALARDOOS WASTELOGO <br />TIERED PERMITTED FACILITY <br />❑ ABOVEGROJND TANK <br />2 <br />1 <br />W' VV <br />b" <br />_ <br />� - �.� 1.1. ��., •L-,•- i �e',( <br />�-s-='.--'-�� \ <br />dA VY <br />❑ <br />' V <br />Fj UST (MONITORING I REILOVAL) <br />ke <br />PWS <br />M HAZARDOUS MATERIALS <br />7 SPILLIRELEASE RESPONSE <br />4 <br />WA -SP QUAD -v <br />SOLID WASTE FACILITY I VEHICLE <br />❑ FOOD FACILDY <br />POOL f SPA <br />(] S Te Mr:GAr,ON <br />DAIRY <br />LAND USE APPLICATION SITES <br />S <br />�.�•� 0 <br />❑ HOUSING <br />SEPTIC PUMPER TRUCK 1 <br />YARD / CHEMICAL TOILETS <br />6 <br />WASTEWATER TREATMENT PLANT <br />F1 HOUSING ABATEMENT <br />T <br />CUPA <br />MOTEUHOTEL <br />CH!CKEN RANCH / DOG KENNEL <br />MEDICAL WASTE FACILITY <br />S <br />CUPA - UST <br />TATTOolswy PIERCING <br />❑ SOLID WAS <br />WASTE TIRE <br />COMPLAINT <br />OTHER(PLEASE SPECIFY): <br />10 <br />gC:AUYfIN� <br />"'BOXED AREA • EHD USE ONLY... <br />