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DATE EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> PV(19 � Avenue,MTast Hazelton/IRONMENTAL HEALTHH ARTMENT -N <br /> 7 <br /> JUN 1 � � (J Tefeph ne: (209)468-3420 Fax (209)464-0on, 2 <br /> CA 52138 Webwww.jgov.org/ehdEWARQU 'V`111 <br /> PAENTALHEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> ---APPLICA LFT f`�IT/S' ,E�1-EtX C0-1,' w t— BUSINESS/AGENCY: - <br /> ADDRESS: CITY/STATE/ZIP: <br /> PHONE(1): $t{L{-'l�Z 7311 PHONE(2): FAX OR E-fJtAIL:Please allow 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 EXPEDITE REQUEST•$130 FEE(CASH OR CHECK ONL//Y�)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT Se2� �(�=;: DATE <br /> 1. List up to ten addresses in the space below. Select the type(s)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 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 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 PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> Eiectronic Information: [-] List ❑ Map-Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS EHD USE ONLY <br /> FILES <br /> UNDERGROUND TANK(UST) Street# Street Name City <br /> CLEANUP SITE(LOP) El CONSUMER <br /> ZOTHER CLEANUP SITE(NON-LO ' k;2_12_q 1 N• / � e l7[ 1_ I" 1WYN_ / <br /> i VHAZARDOUS WASTE v ❑DMRY <br /> EZ/TIERED PERMITTED FACILITY 2 <br /> ABOVEGROUND TANK <br /> PWS <br /> UST (MCH!TCRING(REMCVAL) <br /> 3 <br /> ®/HAZARDOUS MATERIALS <br /> 12/SPILL/RELEASE RESPONSE <br /> WATER QUALITY✓SOLID WASTE FACILITY/VEHICLE 4 <br /> ❑FOOD FACILITY ( <br /> RE MRIGATCN <br /> ❑POOL/SPA � � �{-�J <br /> ❑DAIRY 6 <br /> ❑• LAND USE APPLICATION SITES <br /> {j HOUi:::G <br /> ❑SEPTIC PUMPER TRUCK/ 6 <br /> YARD/CHEMICAL TOILETS <br /> ❑WASTEWATER TREATMENT PUNT EjfCUPA <br /> ❑HOUSING ABATEMENT T <br /> ❑MOTEUHOTEL <br /> CUPA-HAZ-MAT <br /> 17 CHICKEN RANCH/DOG KENNEL <br /> 8 <br /> ❑MEDICAL WASTE FACILITY <br /> ❑TATTOO(eODY PIERCING 6000 WisTE <br /> ❑WASTE TIRE e <br /> ❑COMPLAINT <br /> /OTHER(PLFASE SPECIFY): E]ACCOUNTING <br /> ID <br /> —BOXED AREA-EHD USE ONLY— <br /> Cf'iN <br /> ❑ Records provided by Staff-PPR Complete. Starr Name: <br /> EHD 48-06 <br />