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RECEIVED <br /> S A N J( Y� 2 0 2017 <br /> K4CI- Environmental Health Department <br /> DECLROWENTAL HEALTH UBLIC RECORDS RELEASE APPLICATION <br /> � PEROUSERInCiz <br /> S <br /> _ <br /> Greatness arrows <br /> I-t-ZA EHD LOG NUMBER: 07,0114 <br /> APPLICANT: lyl. BUSINESS/AGENCY: 1Saj�_cJ0XU-r) n Pk) <br /> ADDRESS: hr) Avj�, CITY/STATEIZIP: J520)� u <br /> PHONE(1): (2,04i)14 to 179!V PHONE(2): FAX OR E-MAIL: �L4 y-5 <br /> %/-b <br /> business days from date of application submittal the records to be <br /> Please allow 10 a allable. <br /> Staff will contact o arran!� l ant date and time to review the requested r 'Ord <br /> SIGNATURE OF APPLICANT DATE j 2- 2071-1 <br /> 1. List up to ten address the spaalow[/Ad ranges WILL NOT be accepted. Select the typ (9)of files from the <br /> list below by checking the appropdratyebox(es). =at one file type MUST be selected. Fax to(209)464-0138,mail to the <br /> address indicated below,or email to info(&s[cehd,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$162 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: El List D Map-Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES (Specific addresses only,address ranges will not be accepted) 0. EHD USE ONLY <br /> r derspoumd Tank(USI) street# Street Name city <br /> fi <br /> , Cleanup Site(LOP) <br /> Other cleanup site(Non-LOP) <br /> • .2riEfammous Waste <br /> Xnered Permitted Facility <br /> "" <br /> oesom nd <br /> Tan' <br /> UST 'Man„--rgI <br /> Rmn." <br /> a” <br /> C000q e EPWS <br /> Hazardous <br /> Spla/R Was-Reep.m. <br /> Solid Waste Facility Vehice <br /> 4Fre-rlf 15 elyh vf <br /> ❑Food Facility r- <br /> di CaoCak <br /> El Pool I spa <br /> Dai <br /> ' 9M U. FTWC-k ficmh Caws <br /> D <br /> Land Use Application Sites, <br /> tseptic,Pumper Truck 16 10A I-cen <br /> Yard!Chemical Trusts (Swp Cy m-h(0mrQtr <br /> Wastewater Treatment Plant / SICUPA <br /> <-r L I-11A) Alto <7�7 <br /> QZ HM/HW i�Housing Abalement ? <br /> MWellHofel <br /> chicken perch I Dog Kennel R)P P 7UPA <br /> El Medical West.Facility 144, 0-411 UST <br /> F1 Tattoca Body Piercing nsrs <br /> Xwesta Tire - <br /> .-./Waste <br /> Fj Other(Please Specify): 71 ❑ <br /> — <br /> , BOXED AREA-EHD USE ONLY-* J Acessumme, <br /> Me& Wctf&c: o PF extkA. CL4", 0--- <br /> 0 Records provided by Staff-PPR Complete.Staff Name: FHD-AAR <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br />