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DATE n <br /> SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> JUL �_.� �VIRONMENTAL HEALTH DEPARTMENT` ' FF <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-623 <br /> E�6k fbf PdlCtvtTFt HEAj_ elephone: (209)468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd F <br /> PEPWITISER 1/CES/ PUBLIC RECORDS RELEASE APPLICATION <br /> 1 c <br /> PPLICANT: _ cT G t)-Z i'v'c � BUSINESS/AGENCY: /o I )/JC:f'G le"-, <br /> ADDRESS: - CITY/STATE/ZIP: S' r. , . •?-Ick 7`7. 2- <br /> P <br /> HONE (1): Z j-6, L117^ 6 ?�� 3 PHON (2): U2 j� - 7'e'y— FAX OR E-MAIL: fc / - <br /> Please allow 10 business days from date of application submittal for the records to be vailable. <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> EICHECK BOX TO EXPEDITE EQPESTr$130 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS AYS <br /> SIGNATURE OF APPLICANT ./��/� 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 f209)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 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$130 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 i <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS 3�EHD USE ONLY" ��� <br /> FILES <br /> ❑UNDERGR m TANK(UST) Street# Street Name City 00'� <br /> CLEANUP Sn-E(LOP) U 5"r— PQ(923 .3 J <br /> OTHER CLEANUP SRE(NON-LOP) 1 (� <br /> 33 `• ��� l Sutoi <br /> HAZARDWS WASTE i <br /> n TIERED PERM=FACILRY 2 1 " �DnIRv <br /> n ABOVEGROUND TANK '1�� C q <br /> BUST (MONITORING/REMOV. ) / PWS <br /> Ej 3 / <br /> HAURDWS MATERW.S <br /> 6r � Jn e <br /> SPIWELEAS <br /> RE RESPONSE 77 77 ��^( <br /> SOLIDWASTE FACILRY/VEHICLE p .� ' ❑WATER OuP L <br /> FOOD FACILRY ,� 6C4 <br /> POOL/SPA 0 SSE M(N .N <br /> DAIRY 5 `I <br /> LAND USE APPLICATION SRES <br /> ❑SEPRC PUMPER TRUCK/ S ❑HHS <br /> YARD/CHEMICAL TOILETS <br /> F1 WASTEWATER TREATMENT PLANT <br /> ❑CUPA <br /> I]HOUSING ABATEMENT r <br /> MOTEUHOTEI. <br /> CHICKEN RANCH/DOG KENNEL CUPA- �sr <br /> MEDICAL WASTE FACLr B <br /> IJ TATroo/BODY PIERCING <br /> n WASTE TIRE 9 ❑SOLID WASTE <br /> ❑Cq N-r <br /> ❑OTHER(PLEASE SPECIFY): <br /> 10 ❑AGRWNIING <br /> .BOXED AREA-EHD USE ONLY— <br /> 15106 <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br />