Laserfiche WebLink
19 2017 09:37AM Enviro Assess 8776235493 page 1 <br /> SJ4li,'ib�oaOuiN �E�EIV� on <br /> :.I 4 DEC i mental Health ! e artment <br /> f .__-COUNTY---' 1' 201 P <br /> • � '�rf CrFnhness �USLIC RECORDS RELEA EAPPLICATION <br /> grows herr <br /> . ENMRONM itLtu�"1 <br /> F'EI11T/$ERVICES EHD LOG NUMB -R: <br /> APPLICANT: <br /> ADDRESS: -- BUSINESS/AGENCY: <br /> PHONE (7):LA'13CJ'1J2-7-r-�2-1� <br /> PHONE(2)- CITY/STATElZIP: <br /> kXj <br /> Please allow 10 business days from date of applicafion submittal for e records to be a liable, <br /> Staff will contact to arrange an appoint/nQnt date and time to review the requested r co S. <br /> SIGNATURE OF APPLICANT �,J' r <br /> 1. List uo to ten addresses in the o I k f DATE 7i l <br /> list below by checking the adress <br /> ppropriate box(es).Vgt least'— ranges OT be accepted. Select the <br /> address indicated below or small to info s'cehd.com. Applications received after ted. Fa will bap sJ of files from the <br /> type MUST be selected. Fax t 209 0138 mall to the <br /> business day. pl,; ressed the next <br /> 2. For assistance in Identifying the nature and content of EHD records, please contact EHD at the numbI�r noted below. <br /> 3. The END will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> days after receipt of application. The files will be held for a maximum of flue business days for reuse proximately ten(10) <br /> should be scheduled accordingly. Appointments <br /> 4. Future file reviews by the Same Any file not returned in the same condition as released will be reorganized by EHD staff at the <br /> applicant may <br /> a$152 deposit prio expens' of the applicant. <br /> WELL AND SEPTIC PERMIT ABLE <br /> RECORDS APE AVAILABLErequire <br /> REVIEW: MONDAY•FRID vi 8:00 AM•S:OOPM(EXO,. UDING HOLIDAYS) <br /> iNz <br /> Electronic Information: ❑ List[]Map-Description: <br /> Specific Date Range of Information Requested: From <br /> ENVIRON MENTAL to <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES (Specific addresses only,address ranges will not be accepted) EHD V' <br /> nde ground Tank(UST) <br /> Stet# Street Name ONLY <br /> �IeanuP Site(LOP) �t ` } City I, <br /> .�/Olhw Cleanup Site(Nor. 1 74 ! �v�� I• i—'l,) ❑Couamea <br /> IIQ —nJaus Waste flit.TD <br /> ❑Tiered P9rmhted Facility r <br /> G?%bwegrowd Tank <br /> ❑ONFY <br /> Q'15ST (Monilodng/Rimm <br /> 1:9-laumous Materials S �PWg <br /> RI'Spill/Release Response <br /> 50 Bead vini Fadl2y/Vehicle <br /> d <br /> ❑ <br /> Food Facllly Wanai ouxrry <br /> ❑Pod/Spa j <br /> ❑Dary 5 <br /> 23na MmaAiIax <br /> ❑Land llm Applioadw Sher —'✓ �— <br /> ❑septic Pumper Truck/ <br /> Yard/C Toilets a ❑ <br /> hemiwl Toi Hausiuo <br /> 0`6e8tewaterTreaanerd Plant <br /> ❑Housing Abatement T <br /> C]Motalhiotel CUFA <br /> !� AST/HM/HW <br /> ❑Chicken Rands/Dog Kennel <br /> ❑MIdiral Waste Facllly a CUPA <br /> ❑Tahoo/Body Piercing ;l UST <br /> ❑Wasle Tire a <br /> ❑ Complalril vymre <br /> Other(Please specify); <br /> 10 <br /> ❑A¢puMNo <br /> "`BOXED ARES_AHD USE ONLY"" <br /> ecords provided by Staff-P Com lets. staff Name: <br /> i <br /> olo�am <br /> 1868 E. Hazelton Avenue 1 Stockton, CalifOmia 952051 T 209 46"20 1 F 209 464-0138 1 www.sjcepd.com <br /> Received Time Dec, 19. 2017 10: 51AM No. 2763 <br />