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D �Vbm.ip�qpVEp�+ID SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> d <br /> ENVIRONMENTAL HEALTH DEPARTMENT1 <br /> MAY D 9 2097 1868 East Hazelton Avenue,Stockton, CA 95205-6232 OG <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sacehd.com Email: info(asicehd com <br /> ENVIRONMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> DFDIAITIC <br /> •APPLICANT: r �' C`',k BUSINESSIAGENCY. J�7It <br /> �� <br /> ADDRESS: l? �� CITY/STATE/ZIP: '1 <br /> PHONE(2):r1G`' ���5 n�i�I� 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 you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPE I E REQ ST, $13 (CAS OR CHECK ONLY)-REQUEST PROCESSEDDATE IN 3 BU§IN SS DAYS <br /> SIGNATURE OF APPLICANT '�LIX LSA �I <br /> 1. List up to ten addresses in the spa a below. Address ranges will not be accepted. Select the type(s)of filed from the list <br /> below by checking the appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138, mail to the <br /> address indicated above or email to info ansicehd 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 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. S� 1 <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 FILE ADDRESS <br /> HEALTH DEPARTMENT (Specific addresses only, address ranges will not be accepted) EHD USE ONLY <br /> FILES <br /> UNDERGROUND TANK(UST) Street Street Name city <br /> L ` (7 �CONSUMER <br /> CLEANUP SITE(LOP) Ir <br /> H <br /> ❑ THER CLEAN1 UP SITE Il�j�jC v- I• IV•0` „✓t <br /> AIRT <br /> HAZARDOUS WASTE <br /> TIERED PERMITTED FACILITY 2 '� ^- <br /> ABOVEGROUND TANK Vu PAS <br /> BUST (MONITORING/REMOVAL) 3 <br /> f HAZARDOUS MATERIALS <br /> ATER QUALITY <br /> M SPILURELEASE RESPONSE <br /> I-I SOLID WASTE FACILITY VEHICLE 4 <br /> ❑FOOD FACILITY [3 Sire MIMImwnoN <br /> POOL I SPA /1 SII- L <br /> B W - <br /> DAIRY <br /> LAND USE APPLICATION SITES ❑HOUSING <br /> ❑SEPTIC PUMPER TRUCK/ S <br /> YARD I CHEMICAL TOILETS PA <br /> F1 WASTEWATER TREATMENT PLANT <br /> F1 HOUSING ABATEMENT 7 <br /> I1 MOTEJHOTEL LEA-UST <br /> ❑CHICKEN RANCH I DOG KENNEL B <br /> MEDICAL WASTE FACILITY <br /> SOLID WASTE <br /> TATTOO/BODY PIERCING <br /> WASTE TIRE 9 <br /> Ij COMPIAINT ACCOUNTING <br /> OTHER(PLEASE SPECIFY): 10 <br /> "'BOXED AREA-EHD USE ONLY" <br /> ❑ Records provided by Staff-PPR Complete. staff Name: Ci <br />