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f <br />SAN JOAQUIN Environmental Health Department <br />1: 6--- C G iJ N I Y- PUBLIC RECORDS RELEASE APPLICATION <br />G3;L'GTr').st grOtvc tier <br />SUBMIT BY EMAIL <br />EHD LOG NUMBER: <br />APPLICANT: I; m Belka BUSINESS/AGENCY: EMG <br />ADDRESS: 10461 Mill Run Circle #1100 CITY/STATE/ZIP: Owings Mills, MD 21117 <br />PHONE (1): 800-733-0660x6535 PHONE (2): FAX OR E-MAIL: kbelka@emgcorp.com <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 review the requested records. <br />SIGNATURE OF APPLICANT DATE 7 -�C) 18 <br />1. List up to ten addresses in the space below. 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(a)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:OOPM (EXCLUDING HOLIDAYS) <br />Electronic Information: ❑ List ❑ Map — Description: <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL <br />FILE ADDRESS <br />'3HEALTH CEid <br />DEPARTMENT <br />FILES <br />(Specific addresses <br />only, address ranges will not <br />be accepted) <br />USO LY <br />❑X Underground Tank (UST) <br />Street# <br />Street Name <br />City <br />Cleanup Site (LOP) <br />1 <br />75 <br />West Val ico Road <br />P <br />Tracy <br />STI m, rn l ❑ CONSUMER <br />i'�� <br />X Other Cleanup Site (Non -LOP) <br />F1 Hazardous Waste <br />1 v <br />N* Cop <br />15f❑ DAIRY <br />Tiered Permitted Facility <br />2 <br />l'_,CO <br />Aboveground Tank <br />❑ PWS <br />XQ UST (Monitoring / Removal) <br />Q Hazardous Materials <br />3 <br />Spill / Release Response <br />❑ WATER QUALITY <br />Solid Waste Facility / Vehicle <br />4 <br />E] Food Facility <br />❑ SITE MITIGATION <br />Pool / Spa <br />Dairy <br />5 <br />Land Use Application Sites <br />6 <br />❑ HOUSING <br />Septic Pumper Truck / <br />Yard / Chemical Toilets <br />Wastewater Treatment Plant <br />CUPA <br />Housing Abatement <br />7 <br />AST / HM / HW <br />El Motel/Hotel <br />❑ CUPA <br />Chicken Ranch / Dog Kennel <br />Ej Medical Waste Facility <br />8 <br />UST <br />0 Tattoo/Body Piercing <br />❑ SOLID WASTE <br />❑ Waste Tire <br />g <br />Complaint <br />❑ AccouNTING <br />Other (Please Specify): <br />10 <br />***BOXED AREA - EHD USE ONLY*** <br />9113, 1 _pro-nbtz1 Cr. 7-6 fo <br />"M- PR_ C)S2-112- 1 Itw- P RD 513ry <br />❑ Records provided by Staff -PPR Complete. Staff Name: V EHD 48-06 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />