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RECEIVED <br /> SAN JOA EP 2 1 201 <br /> Environmental Health department <br /> • EN 1 RON8 EKTAL H&M PUBLIC RECORDS RELEASE APPLICATION <br /> PEf rvsEmAGES <br /> EHD LOG NUMBER: <br /> APPLICANT: 1JI[� ) VQ� �QIA�Q I�,. BUSINESS/AGENCY:�Q�1 <br /> ADDRESS: y LZdY`O--Iti $ . CITYISTATEIZIP:, 6c <br /> PHONE(1): g I'�^qU.-'—I yl�L) PHONE(2): FAX OR E- AIL: l�r <br /> Please allow f 0 business days from date of application submittal for the records to be available. X111 <br /> Staff will co��o to arra a ppointment date and time to review the request Tecor s. <br /> SIGNATURE OF APPLICANT Y 1 i'1"�� ��ClCdt—�f DATE1�� <br /> 1. List up to ten addresses in the space below. Ad ress ranges WIL NOT be accepted. Select the types)of files from the <br /> list below by checking the appropriate box(es). At(east one file type MUST be selected. Fax to 12091 464-0139 mail to the <br /> address indicated below,or email to info(a) icehd.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. 1 <br /> 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. f•� <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 <br /> HEALTH DEPARTMENT <br /> FILES (Specific addresses only,address ranges will not be accepted) 11 N L <br /> Underground Tank(UST) Street# Street Name r� �1 <br /> Cleanup Site(LOP) Es t.� IFIL blVb/ n I(oto ❑�� <br /> t �] 1"''•~M~rrvr tNYI <br /> • Other cleanup o (Nan'LOP) �f y- <br /> �Hazallous Waste /1� (� / /l� p LlDA"" <br /> Tiered Permitted Facilityy (�p� CD(zo /1 & — I N �I ` I A t2✓1 /t n <br /> Aboveground Tank / ) JUu C*AT"fVI fT t/.Lf <br /> 101 LIST (Mortaring/Removal) ,iY1 114 N) le �t PWS <br /> 5141p Hazardous Materials f�z) <br /> UU I a •' ` �, mw � <br /> D9spill/Release Response ) Or /t; <br /> •YM Solid Waste Facility/vehicle f� <br /> F1 Faod Facility �t <br /> sne lAncnnox <br /> real <br /> Darr/spa <br /> Dairy G <br /> ❑ K7�� <br /> Land Use Application Sites /� � p Housxc <br /> ❑Septic Pumper Truck/ <br /> Yard/Chemical Toilets <br /> OWastewater etmenl Plant (� �• l ��`,`5m P /�� / ` /(�, CUPA <br /> Housing Abatement CNASTIHMIHV/ <br /> MotellHotel ^' �,/� CUPA <br /> Chicken Ranch/Dog Kennel s-}�- 3o6c�� UST <br /> a <br /> Medical Waste Facility On n1, <br /> Tattooreody Piercing ❑Swo w.�srs <br /> Waste Tire 9 <br /> ❑Complaint <br /> ❑Omer(Please Specify): ❑Accounrixc <br /> t0 <br /> •`•BOXED AREA-EHD USE ONLY— <br /> �i <br /> • ❑ Records provided by Staff-PPR Complete.staff Name: EHD 4306 <br /> 1868 E Hazelton Avenue I Stockton, California 95205 1 T 209 466-3420 1 F 209 464-0'138 1 www.sjcehd.com <br />