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DA�/FQI� �e EHD LOG NUMBER <br />�V SAN .�OAQUIIV ieOUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 r4-1 <br />Jt1� it 0 20't' <br />...rn.�rverrr-cr>-MA PJF-'Rfl ildTelephone:(209)468-3420Fax: (209) 464-0138 Web:vww.sjjgov.org/ehd <br />PUBLIC RECORDS RELEASE APPLICATION <br />E <br />�r � v G -c- c <br />`NPLIe€EZ I Tdf� E -r- j�.;�c <br />/ Q1 / � V�P����� BUSINESS/AGENCY: <br />ADDRESS: IP Zo[ 69pf1i6 pr', S -J!, I CITY/STATE/7-[P: C'I2f^t'l-7,*f 7-[ VV/ I`Mp 2p 5-TCo <br />PHONE (1): PHONE (2): 17± -CPDD FAX OR E-MAIL: ('310I) W'2D - 300-f <br />Please allow 10 business days from date of application submittal for the records to be available. <br />Staff k1dil contact you to arrange an appointment date and time to review the requested records, <br />❑ CHECK BOX TO EXPEDITE REQUEST- $130 FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT I I c/ eA • DATE <br />1. List up to ten addresses in the space below. Select 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) 464-0138 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 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 $130 deposit prior to review. <br />V'VELL 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 2O (tP <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FILE ADDRESS <br />EHD USE ONLY <br />FILES <br />UNDERGROUND TANK (UST) <br />Street # <br />Street Name <br />City <br />1 <br />2�✓ <br />•. I� 1 I Ave, <br />S-)1YY <br />` l <br />-.-"- CLEANUP SITE (LOP)CONSUMER <br />'---.---'OTHER CLEANUP SITE (NON'LQ <br />-AZARDOUS WASTE <br />1H <br />©'TIERED PERMITTED FACILITY <br />2 <br />❑ DAIRY <br />E;rABOVEGROUND TANK <br />BUST (MONITORING /REMOVAL) <br />I^ `! V ❑ PWS <br />dAZARDOUS MATERIALS <br />3 <br />9r <br />SPILL/RELEASE RESPONSE <br />SOLID WASTE FACILITY / VEHICLE <br />/ <br />Q/Wg7.ER. Q.uhLLTY- <br />d <br />FOOD FACILITY <br />5 <br />I SITE MITIGATION <br />POOL/ SPA <br />DAIRY <br />/� /'^ 1 ' ^ 'f 1� <br />111"`///lll�"1►►► 111XWW1111111111 'U(C)✓'1f` JT -11 <br />LAND USE APPLICATION SITES <br />❑ HOus,r:G <br />SEPTIC PUMPER TRUCK / <br />6 <br />YARD / CHEMICAL TOILETS <br />dWASTEWATER TREATMENT PLANT <br />CUPA <br />HOUSING ABATEMENT <br />T <br />MOTEL/HOTEL <br />CUPA - HAZ-MAT <br />❑ CHICKEN RANCH / DOG KENNEL <br />MEDICAL WASTE FACILITY <br />8 <br />TATTOO/BODY PIERCING <br />SOLID 1NA57E <br />WASTE TIRE <br />9 <br />❑ COMPLAINT <br />OTHER(PLEASE SPECIFY): <br />❑ ACCOUNTING <br />10 <br />CVACU AKCA - CITU USC VNLT <br />1 ❑ Records provided by Staff -PPR Complete. Staff Name: ( 7\)A�/)() / / ilAkl;r r' I <br />t;�j25 <br />