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DAT/fit: SAN JOAQUIN COUNTY EHD LOG NUMBER <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />�j 2016 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />Pi=17n,g1T1 a jj <br />EP�l1/IROf1TE,ER!q HEALTH PUBLIC RECORDS RELEASE APPLICATION <br />nCr <br />opo <br />APPLICANT: `� �_� �� C��4&- BUSINESS/AGENCY: <br />ADDRESS: �� � (� , �J (-V�;�, s CITY/STATE/ZIP: ! $CC�LK i �tS 1cab <br />PHONE (1): 6 p`7 4-p-, PHONE (2): a.0c-af q-3, ,�i`,,017CO FAX OR E-MAIL: Cr _l_n�/ �L � l,cCtYtsT <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. CAn <br />❑ CHECK BOX TO EXPED E REQUEST - $139 EE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINE S DAYS <br />SIGNATURE OF APPLICANT ,,tL DATE lb ( 3 ( 6 <br />1. List up to ten addresses in the spa6e 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 $139 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 />HEALTH DEPARTMENT <br />FILE ADDRESS <br />EHD USE ONLY <br />FILES <br />UNDERGROUND TANK (UST) <br />Street # <br />Street Name <br />City <br />LV <br />�(s,, m VV <br />J_t__ .tU <br />E] CONSUMER <br />I 111 PI /40 <br />CLEANUP SITE (LOP) <br />OTHER CLEANUP SITE (NON -LOP) <br />d HAZARDOUS WASTE <br />_ <br />❑DAIRY <br />dTIERED PERMITTED FACILITY <br />ABOVEGROUND TANK <br />❑ PWS <br />I-1 UST (MONITORING / REMOVAL) <br />HAZARDOUS MATERIALS <br />3 <br />LI SPILL/RELEASE RESPONSE <br />4 <br />WATER QUALITY <br />SOLID WASTE FACILITY / VEHICLE <br />WOOD FACILITY <br />5KSjTr MITIGATION <br />POOL / SPA <br />DAIRY <br />5 <br />LAND USE APPLICATION SITES <br />HOUSING <br />❑ <br />SEPTIC PUMPER TRUCK / <br />B <br />YARD / CHEMICAL TOILETS <br />❑ WASTEWATER TREATMENT PLANT <br />4CUPA <br />HOUSING ABATEMENT <br />7 <br />MOTEL/HOTEL <br />CUPA - UST <br />CHICKEN RANCH / DOG KENNEL <br />MEDICAL WASTE FACILITY <br />8 <br />TATTOO/BODY PIERCING <br />SOLID WASTE <br />F1 WASTE TIRE <br />g <br />COMPLAINT <br />OTHER(PLEASE SPECIFY): <br />❑ ACCOUNTING <br />10 <br />—BOXED AREA - EHD USE ONLY*** <br />p l <br />