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RECEIVED4,,� <br /> SAN��JOAQUIN orl `r, mEnvironmental Health Department <br /> it ✓�T-te� 3 v PUBLIC RECORDS RELEASE APPLICATION <br /> —COUNTY --- E�MROtvMts�t:AL hI�ALI�i <br /> Greatness grows here. PERMIT/5ERVEGES <br /> • hn,Se((on4r d a caS;GGIR �2S.%uyhEHDLOG NUMBER:197 26 • <br /> APPLICANT: 0 BUSINESS/AGENCY: 2..- <br /> ADDRESS: CITYISTATE/ZIP: .1S <br /> PHONE(1): PHONE(2):Zoq- 21171-S29J FAX OR E-MAIL: <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will con t to fan an appointment date and time to review the requested vecorAs. <br /> SIGNATURE OF APPLICANT DATE JCJ/2 G <br /> 1. List up to ten addresses in a space below. Address ranges WILL NOT be accepted. Select the t e(s of files from the <br /> list below by checking the ppropriate 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(ar)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. O� / <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:OOPM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List❑ Map-Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL FILE ADDRESS <br /> HEALTH DEPARTMENT (Specific addresses only,address ranges will not be accepted) <br /> FILES EHD USE ONLY <br /> _ffunderground Tank(UST) Street# Street Name city <br /> Cleanup Site(LOP) /,,, ❑CONSUMER <br /> Other Cleanup Site(NOO-LOP) <br /> �azardaus Waste ❑ <br /> D. <br /> Z M c .� <br /> �'l iered Permitted Facility 2 �� L V�t Tlry <br /> Q,Abowground Tank PWS <br /> VuST (Monitoring I Removal) <br /> [ �r,�►e�-rn�l2e s�. <br /> Hazardous Materials <br /> aspill/Release Response WPl£R OuwTr <br /> Solid Waste Facility/vehicle q <br /> ❑Food Facility Sire MInaADON <br /> F1 Pool I Spa Dalry '1l, err. <br /> a tV�� / l� <br /> ❑Land Use Application Sites 9 ❑HOUSING <br /> Septic Pumper Truck 1 a <br /> Yard I Chemical Toilets <br /> Wastewater Treatment Plant COPA <br /> Housing Abatement T ASTlHM/HW <br /> ❑Motel/Hotel CUPA <br /> ❑Chicken Ranch/Dog Kennel UST '.. <br /> a <br /> Medical Waste Facility <br /> TattodBody Piercing Soule wnsre <br /> ❑Waste The 9 <br /> ❑Complaint <br /> Other(Please Specify): ❑AccouxnxO <br /> 7a <br /> *-BOXED AREA-EHD USE ONLY*" i <br /> eb9rn fCa'W a( l+1 0� v fry e t 1� <br /> ❑ Records provided by Staff-PPR Complete. staff Name: sHoge-os <br /> s <br /> 1868 E. Hazelton Avenue I Stockton, California 952D5 T 20968-3420 F 209 464-0138 1 www.sjcehd.com <br />