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n:Erik Brawn Fax (888)828-2635JPrcLpZ.&& (208)464-0138 Page 2 of 2 12/28/2017 10:52 AM <br /> pmffEbSAKAMIU1 <br /> EnvirolirnerAp <br /> Heafth Department <br /> .'. — <br /> ;COJJ I DEC 2 S 2017 P �BLIC RECORDS RELEASE APPLICATION <br /> , . .r.,-= fi/•sotnksa �roras h'611111 1YTALHEALTH ,\\� <br /> EHD LOG NUMBER: <br /> APPLICANT: BUSINESSIAGENCY; i.E-,� <br /> ADDRESS: ( •r CITYISTATEIZIP; f�/,pRfti_ •F H;p) <br /> PHONE(1): �j2Jr '2.b°-L �;j of I PHONE(2): 2., ' o r s• 311 FAX OR E-MAIL: <br /> 0, coft <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to arran n poin It date and time to review the requested records, gy <br /> SIGNATURE OF APPLICANT - DATE <br /> M1. List uo to ten addresses in the space � ddre es WILL NOT be accepted- Select the types)of Files from th <br /> list below by checking the appropriate box(es). At least one file type MUST be selected. Fax to f209)464-02383 mail to the <br /> address indicated below <br /> business day, or email to infor&sicehd com Applications received after 3:00 pm will be processed the next <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 flies 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$152 deposit prior to review. ' /I(1 <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM•5:00PM(EXCLUDING HOLIDAYS) <br /> Electronic Information; ❑ List❑Map– Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS g� <br /> FILES (Specific addresses only,address ranges will not be accepted) EHD USE ONLY <br /> tunderground Tank(OSr) Street# <br /> GStreet Name �— city <br /> eanup Site(LOP) y��Fl�.r ❑ k <br /> (Other Cleanup Site(Non-LOP) 1 �J tJ Q C a � cousummVHazedous West.ATid Pnrmltted Facility 2 ,eAboveground Tank <br /> ,RUST (Monitoring/Removal) ❑PWS <br /> ®J-Iazardous Matenais ' <br /> Spill 1 Release Response <br /> F1 Solid Waste Facility I Vehicle 4 l j–J.47j-{, ye Amy Qua rry <br /> n Food Fadlity /i. <br /> rzz- <br /> F1 Pool/Spa '.�k� <br /> E]Dalry S -MmG— <br /> Land Use Application 81. <br /> El Septic Pumper Truck/ 6 v— ❑Houswa <br /> Yard/Chemical Toilets <br /> I]Wastewater Treatment Plant <br /> Housing Abatement 7 COPA <br /> Motel/Hotel AST/HM/HW <br /> F1 Chicken Ranch/Dog Kennel <br /> g <br /> Medical Waste Facility Ct1PAusr <br /> E]Tattoo/Budy Flaming <br /> Waste The a p Saup WnsrF <br /> Complaint <br /> Olper(Please specify} - <br /> 10 ❑Accwt nno <br /> 'BOXED ARFA-Flurn USE ONLY^' /� <br /> Of- PC <br /> n 1- '{�f^l@ O•L �0. bR-. VQ 1.112 . 1-CJt� <br /> fv%AU IV dI <br /> 09, <br /> Im',6hortlo e5 <br /> ❑ Records provided b Staff-PPR Complete. staff Name: <br /> etloge-oe <br /> 1868 E. Hazelton Avenue I Stockton, California 95265 I T 209468-3420 1 F 209 464-0138 1 www.sjcehd.com <br /> Received Time Dec. 28, 2017 10:46AM No. 2795 <br />