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&. e, LE <br />MAY 19 2017 �2 <br />SAN JOAQUIN COUNTY <br />VIRONMENTAL HEALTH DEPARTMENO <br />18 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.org/ehd <br />PUBLIC RECORDS RELEASE APPLICATION <br />EHD LOG NUMBER <br />VG(�2, <br />APPLICANT: .,.t»In/..� (r), ni5(ALA_-I"s.rJ BUSINESS/AGENCY: <br />ADDRESS: `% {J}/t C CITY/STATE/ZIP: <br />PHONE (1): PHONE (2): FAX OR E-MAIL: r7 -�27 c) D <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 />❑ CHECK BOX TO EXPEDITE R�EjQ/ UEST - 13 FEE (CASH OR CHECK ONLY) -REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT 1 G M . DATE J- <br />1. <br />/7 <br />1. List up to ten addresses in the pace 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 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 $139 deposit prior to review. <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:OOPM (EXCLUDING HOLIDAYSY Z� <br />Electronic Information: ❑ List ❑ Map — Description: <br />Specific Date Range of Information Requested: From <br />to <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FILE ADDRESS <br />EHD USE ONLY <br />FILES <br />UNUERGROUND TANK (UST) <br />Street # <br />Street Name <br />City <br />� �3D� � wY <br />_ CONSUMER <br />�� I ❑ <br />CLEANUP SITE (LOP) <br />µ/ I OTHER CLEANUP SITE (NON -LOP) <br />01 <br />_AJ COMW <br />E DAIRY <br />HAZARDOUS WASTE <br />Y'®' <br />TIERED PERMITTED FACILITY <br />2 <br />ABOVEGROUND TANK <br />PWS <br />UST (MONITORING / REMOVAL) <br />HAZARDOUS MATERIALS3 <br />S <br />t" L9 SPILLIRR EASE RESPONSE <br />WATER QUAL TY <br />+�L I SOLID WASTE FACIUTY / VEHICLE <br />/� <br />4 <br />❑ FOOD FACILITY <br />RI'SITE MRIGATION <br />❑ POOL i SPA <br />❑ DAIRY <br />6 <br />FNS LAND USE APPLICATION SITES <br />HOUSING <br />SEPTIC PUMPER TRUCK/ <br />6 <br />YARD / CHEMICAL TOILETS <br />❑ WASTEWATER TREATMENT PLANT <br />CUPA <br />❑ HOUSING ABATEMENT <br />7 <br />❑ MOTEL/HOTEL <br />CUPA-UST <br />❑ CHICKEN RANCH / DOG KENNEL <br />❑ MEDICAL WASTE FACILITY <br />8 <br />TATTOO/BODY PIERCING <br />❑WASTE TRE <br />T <br />//�� D <br />M i n/f � $OLIO WASTE <br />„1 <br />9 <br />COMPLAINT <br />E Acmu- <br />OTHER(PLEASE SPECIFY): <br />10 <br />—BOXED AREA - EHD USE ONLY - <br />1 <br />i <br />- __' _- - - '' ����� •SflILJ/ ro/ t �L Mill A it <br />111 . <br />EHD 48-06 CA:) <br />unawJ lab- I l dy ItTj. LP <br />