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ItTl TEA V l I EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> APR 14 ni'l 6VIRONMENTAL HEALTH DEPARTMENIO <br /> 1868 East Hazelton Avenue, Stockton, CA 96205-6232 ?;SqLij <br /> Telephone: (209)468-3420 'Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> ENVIRONMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICA r7 SUSINESSIAGENCY: —f <br /> ADDRESS: n r CITY/STATE/ZIP: 6. <br /> PHONE (1): ( - PHONE. (2): FAX OR E-MAIL: cl/•,ry0 <br /> Pk ase allow 10 business days from date of application submittal for the records to be available. es <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$139 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE. -] u-1__7 <br /> 1. List uv to ten addresses in the p ce below. elect 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. LA A[ <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 i-al-( A J qYIT <br /> HEALTH DEPARTMENT FILE ADDRESS EHD USE ONLY <br /> FILES <br /> UNDERGROUND TANK(LIST) Street# Street Name City C <br /> CLEANUP SITE(LOP) y(�..,/��� El CokSUIUER <br /> ( ao MA4'in sP <br /> OTHER CLEANUP SITE NON-LOP) <br /> I]HAZARDOUS WASTE E]DAIRY <br /> E]TIERED PERMITTED FACILITY 2 <br /> ABOVEGROUND TANK <br /> ❑PWS <br /> UST (MONITORING/REMOVAL) <br /> 3 <br /> HAZARDOUS MATERIALS <br /> SPILLIRELEASE RESPONSE E]WATER QUALITY <br /> SOLID WASTE FACILITY I VEHICLE 4 <br /> FOOD FACILITY - <br /> © SITE POOL/SPA [f MITIGATION <br /> DAIRY $ <br /> LAND USE APPLICATION SITES <br /> H©USING <br /> SEPTIC PUMPER TRUCK 1 6 <br /> YARD I CHEMICAL TOILETS <br /> F]WASTEWATER TREATMENT PLANT ❑CUPA <br /> ❑HOUSING ABATEMENT <br /> M07EL/HOTEL CUPA-UST <br /> CHICKEN RANCH/DOG KENNEL <br /> ®MEDICAL WASTE FACILITY <br /> F-1 TATTODIBODY PIERCING ❑SOLID WASTE <br /> ❑WASTE TIRE 9 <br /> F�COMPLAINT <br /> ACCOUNTING <br /> OTHER(PLEASE SPECIFY): [] <br /> 10 <br /> —BOXED AREA-EHD USE ONLY— <br /> c y <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 48-06 <br />