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�' VED JOAQ[Ji<<! COUNTY EHD LOG NUMBER <br /> L,.,IRONMENTAL HEALTH DEPARTMENT ,.d <br /> MAY E r`016 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)464-0138 Web:vvww.sjgov.org/ehd <br /> :=NVIRONMIENTALHEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> f V tr�yfl <br /> 'PLICAN'T: (.4 ;. �t-�.f "It�,s �c�. BUSINESS/AGENCY: <br /> ADDRESS: _�Qi ! ?2.,l �-.Jk- )G'7 CITYfSTATE1ZIP: - <br /> PHONE (1): �s � � S' -�� �'j PHONE(2): %-.711' - 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 /> Q CHECK 13OX TO EXPEDITE REQUEST-$130 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED 1N 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICAIti1Tf � � - --'" <br /> /�� � %�....----`"7 DATE <br /> 1. List uta to ten addresses in the space below. Select the types) of files from the list below by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to 209 464-0138 or mail to the address indicated above. Address <br /> ranges will not be accepted.Applications received after 3:00 pm will be processed the next 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 irrill notify the applicant if any EHD files exist. An appointment for revievJ will be confirmed approximately ten (16) <br /> days after receipt of application. The files will be held for a maximum of five business days for revievJ. Appointrienits <br /> should be scheduled accordingly. <br /> 4. Any file not returned In the same cond'tion 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$130 deposit,prior to review. <br /> WELL AND SEPTIC PERfYIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> Electronic Inflormatlan: ❑ List ❑ Map- Description: <br /> Specific Date Range of Information Requested: From / V;6i to /— <br /> ENVIROhII'�ENTAL �-f'M�P '�%/ 1, •' �' � �- �� <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES EHD USE ONLY <br /> UNDERGROUND TANK(UST) Street# Street('`dame city <br /> CLEANUP SrTE(LOP) j- <br /> / /� �� r lGlrrY.�l l-Ls^•C� �,`7CGt�}�w� /W fiThA`" �,�oNsyM51r�. <br /> i OTHER CLEANUP SITE(NGN-L 1 'I�o <br /> h�' HAZARDOUS WASTE <br /> ❑UAIHY <br /> ®'TIERED PERMITTED FACILITY 2 <br /> ABOVEGROUND TANK <br /> UST 1,?0 N!TCP!NG I F?EF.7D".FP!) ❑PWS I <br /> Q HAZARDOUS MATERIALS 3 <br /> IJ SPILLIRELEASE RESPONSE <br /> SOLID WASTE FACILITY I VEHICLE 4 <br /> fay VATER QUALITY <br /> F-1 FOOD FACILITY <br /> PCDL I SPA ®SITE MITIGATION <br /> DAIRY 5 <br /> F-I LAND USE APPLICATION SITES - <br /> SEPTIC PUMPER TRUCK/ El Houst,,qt; <br /> s vel".a <br /> YARD I CHEMICAL TOILETS <br /> F-1 WASTEWATER TREATMENT PLANT CUPA <br /> HOUSING ABATEMENT 7 I <br /> []MOTEL/HOTEL <br /> F II <br /> ❑CHICKEN RANCH/DCG KENNELCUPA-HAZ-MAT <br /> S <br /> MEDICAL WASTE FACILITY <br /> TATTOO/BODY PIERCING <br /> i�WASTE TIRE 8 E]SCUD WANE <br /> COMPLAINT <br /> CTHER(PLEASE SPECIFY), <br /> [ 10 ❑ACCOfJNT1NG <br /> WIG <br /> "•BQXFD AREA-EH USE ONLY'— <br /> I <br /> ❑ Records provided by Staff-P PR Com plete. staff Name: <br /> EHD 48-06 <br />