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SAN-JOAQUgECE'VE ' <br /> Environmental Health Department <br /> ra --COUNTY--- JAN 110 2018 PUBLIC RECORDS RELEASE APPLICATION <br /> Ill <br /> Gr=otnes<_ grgtvs h�Ifl NTA1 HEALT1-I 7 <br /> �lcmirrig€MO� EHD LOG NUMBER.. <br /> V <br /> f �� <br /> ea <br /> APPLICANT: AmV _STP) T--7-E2 BUSINESS/AGENCY:S7C-F0bk IC NCR-y-S <br /> ADDRESS: I9-YO E, WA?FLT-DN RvE CITY/STATEMP;sSLKN r C.A 9520 S- <br /> PHONE(1): PHONE(2): 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 yp arrang a oin nt date and time to review the requested records. <br /> SIGNATURE OF APPLICANT / DATE I ( 10 I 1 LC <br /> 1. List un to ten addresses�in a spa elow. Addqrah ranges WILL NOT be accepted. Select the e(s)of files from the <br /> list below by checking the appropriate box(es). A ast one file type MUST be selected. Fax to(209)464-0138, mall to the <br /> address indicated below,or email to info(dsicehd.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. I <br /> Future file reviews by the same applicant may require a$152 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List❑ Map—Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL FILE ADDRESS t <br /> HEALTH DEPARTMENT 3 <br /> FILES (Speck addresses only,address ranges will not be accepted) USE ONLY <br /> Underground Tank(UST) Stroat# Street Name City T <br /> Cleanup Site(LOP) 7I' p r� y/� a E]Coostw.m ##gg <br /> Other Cleanup Site(Non-LOP) , DIJ yvatnlit-+l CIIT ve 11 rbrn' <br /> Hazardous Waste wr <br /> 5 <br /> Tiered Permitted Facility a Q`j Cl 1/�/p �y7 6nl/e <br /> Aboveground Tank I✓iJ 1 ( Y lMl t "���1 I f"1 I r Vi 0 r h <br /> UST (Moritonng/Removal) /nV�I /t J�,,�� PWS <br /> Hazardous ..Mumble <br /> Resp 9 I`4 S7 In//: I/In 0 6 ave, Ed <br /> �bm 10 r� <br /> Spill/Release Response 11 I r T LUl/JNN rl <br /> J MINA.Ouunv <br /> Solid Waste FacilFacility4/Vehicle .-�"U J C7 V6VC 11 lYl C <br /> Food Facility y ag 1' <br /> ❑Pool/Spa /,/ sna Mmsnrrou ' <br /> 9Da5 ggDq wCtpA.w, �-)yliveThlimfm is <br /> N <br /> Land Use Application Saes <br /> ousiNo <br /> 9Seplic Pumper Truck/ a �b 1 _ <br /> Yard/Chemical Toilets t/Tl(AJLt'I LIQ I ��)��- I{'tbYh-'o+ 1 <br /> Wastewater Treatment Plant <br /> ❑ + CUPA <br /> Housing Abatement l qXlVaul6iMVVe Pd Dmtw AST/HM/HW <br /> Motel/Hotel <br /> Chicken Ranch/Dog Kennel {- �t t/A\/e y�,II 1 CUPA <br /> ❑Medical Waste Facility S toy SD w (L..t CIr Uyt Qd �bm� y� UST <br /> ❑Tattoo/Body Pieroing ` jrl� SMID WASTE ttiYpYpYp <br /> Waste Tire e I 1 g <br /> Complaint U41 IV•15I 0 Om <br /> kt <br /> ❑Other(Please Specify): ❑AccouNrrvo i <br /> ,o <br /> *"BOXED AREA-EHD USE ONLY-- <br /> iiL0t `E ' aA a A, ra lrt' ,+ a( R:Rta �nEo McA sL$e)µ an lX z 'firer 021'" <br /> ❑Records provided by Staff-PPR Complete.Start Name: EHD 4840 <br /> I <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />