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L` <br />• <br />S A N J 0 A Q U I N Environmental Health Department <br />— COUNTY— PUBLIC RECORDS RELEASE APPLICATION <br />P�I"i6'4AIT� ' EMAIL <br />EWI� l nn,,yy�� -157 <br />��N'•`EHD LOG NUMBER: (3�3 <br />APPLICANT: � C V+V) `D11MI) BUSINESS/AGENCY: <br />ADDRESS: I to CI "}�,_S } 9 Uhb�4 CITY/STATE/ZIP: <br />PHONE (1): >'�101) �, 5� (T4Y6 PHONE (2): `)tU 41D I J�6 1 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 ou to arrange an pointment d and time to review the requested re <br />co <br />SIGNATURE OF APPLICANT %. 4' DATE <br />1. List up to ten addresses in space below. A�rre s anges WILL NOT be accepted. Select the types) Iles 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. L %I <br />Future file reviews by the same applicant may require a $152 deposit prior to review. J l <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 pG,C1, iz,-A I—t0f v -S to <br />ENVIRONMENTAL <br />FILE ADDRESS <br />HEALTH DEPARTMENT <br />FILES <br />(Specific addresses <br />(p <br />only, address ranges will not <br />y 9 <br />accepted) <br />be acce ted <br />EHD USE ONLY <br />Underground Tank (UST) <br />Street # <br />Street Name <br />City <br />d <br />_' 1/ <br />`D <br />p <br />�� i r � " V <br />,`{ <br />�'I0LL� <br />1 <br />14A j 1 vv'AJ M CONSUMER <br />N© rCj1 V�,/ <br />Cleanup Site (LOP) <br />dOther Cleanup site (Non -LOP) <br />Hazardous Waste <br />✓Tiered Permitted Facility <br />2 <br />f v <br />/J <br />Tri C0.> RR� <br />1�) <br />��` <br />r% <br />N.0 © AIRY <br />, [ <br />VCl/ <br />N9 W <br />Aboveground Tank <br />UST (Monitoring /Re a <br />I <br />��� ��• <br />1 <br />1 <br />[ii <br />i1i� <br />© [APWS <br />Hazardous Materals <br />. <br />6"j10 <br />�" CY ! <br />Spill 1 Release Response <br />©WATER QUALITY <br />Solid Waste Facility I Vehicle <br />4 <br />Food Facility <br />MITIGATION <br />Pool I Spa <br />Dairy <br />5 <br />Land Use Application Sites <br />HOUSING <br />Septic Pumper Truck 1 <br />6 <br />Yard I Chemical Toilets <br />f(_ <br />laWaslewaler Treatment Plant <br />Q CUPA <br />�HousingAbatement <br />7 <br />ASTIHMIHW <br />Aotel/Hotel <br />ig/CUPA <br />12'hicken Ranch I Dog Kennel <br />6 <br />UST <br />Medical Waste Facility <br />/ <br />yTalloo/Body Piercing <br />&SOUL WASTE <br />Waste Tire <br />g <br />VComplaint <br />❑ AGGOUNTINO <br />Other (Please Specify): <br />Arleiw o, i"A <br />� <br />,o <br />BOXED AREA - EHD USE ONLY <br />❑ Records provided by Staff -PPR Complete. Staff Name: EHo4&a8 <br />1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />