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SALMON O N RECE��',��ri ental Health Department <br /> --COUNTY-- 1t)tr PUBLIC RECORDS RELEASE APPLICATION <br /> 5�r• �i <br /> I G.cuLless grow^ herr. gi-� /�� <br /> ENVIRONMENTAL HEALTH EHD LOG NUMBER: d <br /> APPLICANT: 7/"-1 � mS BUSINESS/AGENCY: &e-cc- <br /> ADDRESS' .3l40 &X�/ic p/!C, /74' St J0_0 CITY/STATEIZIP: Oafeyc 9S7`fZ <br /> PHONE(1):( q/16) &31 -'/1`6 PHONE(2): M rsc19' -3-LS6 FAX OR E-MAIL: fJc'/yc'r CJ CtVC64446 6(rNj <br /> Please allow 10 business days from date of application submittal for the records to be= <br /> Staff will contact you t9 Fran n appointment date and time to review the requested records. <br /> SIGNATURE OF APPLICANT \ / ��y�— DATE e,7S /iiz <br /> 1. List un to ten addresses in the space below. Address ranges WILL NOT be accepted. Select the types)of files from the <br /> list 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 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. <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. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM•5:00PM(EXCLUDING HOLIDAYS) 1� 'i <br /> Electronic information: ❑ List Map—Description: cr £ � crrwciKe 61 bs/u/C C% rl�a>a�/c{, (hu i Gf <br /> Specific Date Range of Information Requested: From to see <br /> ENVIRONMENTAL FILE ADDRESS Ave <br /> HEALTH DEPARTMENT ( p y 9 accepted) EHD USE ONLY <br /> FILES (Specific addresses only,address ranges will not be ecce ted <br /> Underground Tank(UST) Street# Street Name city <br /> Cleanup sn,(LOP) "''''t� 1 0 CONSUMER <br /> Other Cleanup Site(Non-LO Q.CA`�/ <br /> Hazardous Waste co 0 DAIRY <br /> ®Tiered Pencilled Facility 2 <br /> Aboveground Tank <br /> UST (Monitoring/Removal) <br /> 0 PWa <br /> [K]Hazardous Materials S <br /> Spi I Release Response <br /> Solid Waste Facility/Vehicle 4 1 C]WATER QUALM <br /> Facility W <br /> ❑Pool/spa / _ \//i 0 SUE Mmoearou <br /> ❑Dairy 5 l �/1 tyy)' t /�`.O _ <br /> Land Use Application Sites <br /> 13 HouslNa <br /> Septic Pumper Truck/ <br /> 6 <br /> Yard/Chemical Toilets <br /> Waslewffier Treatment Plant rd CUPA <br /> ❑Housing Abatement 7 AST/HM/HW <br /> El MotellHotel <br /> F]Chicken Ranch/Dog Kennel ❑CUPA <br /> 6 UST <br /> ❑Medical Waste Facility <br /> �❑Tattoo/Body Piercing 0 Saw W vr% <br /> DKI waste lire g <br /> ®Complaint <br /> ❑ <br /> Other(Please Specify): ❑AcmuNma <br /> 0 <br /> --BOXED AREA-EHD USE ONLY'*' <br /> P 'A 45 f I F F <br /> 0 Records provided by Staff-PPR Complete. staff Name: eifo 4A no <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />