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tECE1VED <br /> SAN J OAQ U I NJUL 12 2018 Environmental Health Department VI <br /> TT C 0lJ N T Y----- PUBLIC RECORDS RELEASE APPLICATION <br /> Great le orov,,; be,§NVIR0NMENT �I F <br /> PEF;tHRIT/�[ , ,�g BY EMAIL j-%-) EHD LOG NUMBER: r <br /> APPLICANT: LRL1_r'eJ : qA"-C BUSINESS/AGENCY: S;(C" (,(i�U90rf,S <br /> ADDRESS: 1r?;��nttAve. _ CITY/STATE/ZIP: Lj c <br /> PHONE(1): `!- _ - ,` PHONE(2): FAX OR E-MAIL: VSs ra sSj �a <br /> Please allow 10 business days from date of application submittal for the records to be available. t <br /> t <br /> Staff will contact u to arran, an appointment date and time to review the requested records. <br /> SIGNATURE OF APPLICANT�'� C c� / DATE � J_1„7 (F'� <br /> 1. List up to ten addressesjn the space below. Address ranges WILL NOT be accepted. Select the r <br /> P g p type(s)off iles from the F <br /> list below by checking-he appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138,mail to the <br /> address indicated below,or email to info(a-)sicehd.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. t <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 $152 deposit prior to review. 7/1> <br /> - <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List❑ Map—Description: a <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL FILE ADDRESS Cb i(Pl . <br /> HEALTH DEPARTMENT ( ponly, 9 p <br /> FILES S ecific addresses address ranges will not be accepted) EHD USE ONLY <br /> ti <br /> Underground Tank(UST) Street# Street Name City <br /> i <br /> Cleanup Site(LOP) CONSUMER <br /> `^`_ �CONSUMER ;I <br /> Other Cleanup Site(Non-LOP) 1 �Fo F ) <br /> 4Hazardous Waste (�ln [yam ($ DaiRr hk <br /> E�Tiered Permitted Facility 2 <br /> �4� .�,,per, C <br /> Aboveground Tank f t /, 1�1 Omini, Cal <br /> app <br /> Y <br /> UST (Monitoring!Removal) iv T, T ❑PWS <br /> Hazardous Materials 3llAA'' <br /> Spill!Release Response J J v. = T!�i 1 ft v l <br /> Solid Waste Facility/Vehicle4 0't0 T jj'jj•F• 12ATER QUAH Y <br /> k <br /> E]Food Facility • j i?��r �!�'Y\ NO iw, co <br /> SP <br /> z <br /> E7 Pool!Spa (7/ ; SITE ;nGAnON d <br /> Dalry s S Vv vv <br /> Land Use Application Sites <br /> Septic Pumper Truck! a �Ih tC OUSING <br /> Yard!Chemical Toilets s-, ul <br /> i Wastewater Treatment Plant l{ 1 Y�\ 41,- I }rnn CUPA I <br /> �Housing Abatement 7 111h,1�h/ MWj 1+Mi AST/HM/HW II <br /> 1771 MotellNotel <br /> Chicken Ranch!Dog Kennel UPA <br /> a UST <br /> []Medical Waste Facility <br /> []Tattoo/Body Piercing Souq waste u <br /> Waste Tire 9 <br /> Complaint 6 <br /> []other(Please Specify): p AccouNnNG <br /> 10 <br /> i± <br /> ***BOXED AREA-EHD USE ONLY <br /> 10119 Vr_uddedt -0(n f�ut - n ffvV (2 <br /> I S. L .��. ��� s.�kwol '14 <br /> 7[0 Records provided by Staff-PPR Complete. staff Narne: - &C-D E1-1130.06 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />