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9 <br />0QAW-..,J0AQU1N <br />-- __ C O U Ri TY--- - <br />NECEIVED <br />JAN 3'1 ,.-Environmental Health Department <br />PUBLIC RECORDS RELEASE APPLICATION <br />ENVIRONMENTAL HEALTf-I <br />PERMl7/SER 'CES EHD LOG NUMBER:'37qo' <br />APPLICANT: V� it S BUSINESS/AGENCY: C�— <br />ADDRESS: � ck( t L CITY/STATEIZIP: <br />PHONE (1): r,�j(- %(,jZ� P ONE (2): FAX ORE -MAIL: <br />Please allow 10 business days from date of application submittal for the records to be available. c WL,-,- Cb WL <br />Staff will contact you to arran ap ' ment date and time to review the requested records. LJ <br />SIGNATURE OF APPLICANT DATE <br />1. List up to ten addresses in the space be ow. Address 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 (209) 464-0138, mail to the <br />address indicated below, or email to info(o)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) r <br />I Electronic information: ❑ List ❑ Map - Description: �-�, _ I <br />Specific Date Range of Information Requested: From / k i L ) to <br />ENVIRONMENTAL <br />FILE ADDRESS <br />HEALTH DEPARTMENT <br />FILES(Specific <br />addresses <br />only,address ranges will not <br />be accepted) <br />EHD USE ONLY <br />Underground Tank (UST) <br />Street # <br />Street Name <br />City <br />i <br />t il3 <br />jf n <br />( <br />�C(71 A4 <br />� � J ` <br />❑ CONSUMER <br />' <br />'��� iv � LL ) <br />Cleanup Site (LOP) <br />her Cleanup Site (Non -LOP) <br />-lazardous Waste <br />_:a1��G� �� i �t7rl Fi..ift <br />r' <br />❑ DaRv <br />Tie d Permitted Facility <br />2 <br />t <br />Aboveground Tank <br />El PWS <br />ST (Monitoring / Removal) <br />-z rdous Materials <br />s <br />Spill / Release Response <br />[g'NATER QUALITY <br />Solid Waste Facility / Vehicle <br />4 <br />F] Food Facility <br />SITE MITIGATION <br />F� Pool / Spa <br />0 Dairy <br />5 <br />F] Land Use Application Sites <br />❑ HouslNc <br />F1 Septic Pumper Truck / <br />s <br />Yard / Chemical Toilets <br />Wastewater Treatment Plant <br />y❑<0PA <br />I] Housing Abatement <br />7 <br />AST I HM I HW <br />Motel/Hotel <br />i <br />CUP. <br />1771 Chicken Ranch / Dog Kennel <br />Medical Waste Facility <br />8 <br />USI <br />Tattoo/Body Piercing <br />SOLID WASTE <br />Waste Tire <br />g <br />Complaint <br />❑ ACCOUNTING <br />other (Please Specify): <br />iD <br />'BOXED AREA - EHD USE ONLY' <br />�??�-�U ` ��tttf:G�l /�,. ;�t"tl'rrL:'\ I ".v,0� r:'P^ 1 r�� <''\�•�s�Qt.� b�" GiC:lri°-"2 C�ti�- 4./1'.-I/T.G - ?h¢�l'�. _ � 7v �-��.^""' <br />. I <br />❑ Records provided by Staff -PPR Complete. staff Name: EHD 48-06 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br />