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RECEIVE[ <br /> SANJOQQUIN jAtj 31 2,-Environmental Health Department <br /> ----C O U r\I TY --- PUBLIC RECORDS RELEASE APPLICATION <br /> eo; ss. grcvat l"-Cr . ENVIRONMENTALH u <br /> PERMIT'I,,CESLTH EHD LOG NUMBER: l© <br /> • <br /> APPLICANT: _ (� ('t S se-J\ BUSINESS/AGENCY: F-f4 &— <br /> ADDRESS: F.06[C. CITY/STATEIZIP: [. 6!4S6AjlI j5- <br /> PHONE(1): ,3(-7 7� 6t�S-9 — PWONE(2): FAX OR E-MAIL: rn 0(-I rl t,15 p S Pc� <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to affan ap . ment date and time to review the requested records. l <br /> SIGNATURE OF APPLICANT DATE <br /> 1. List up to ten addresses in the space below. Address ranges WILL NOT be accepted. Select the type(s)of files from the <br /> list below by checking the appropriate 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(d,)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. <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) V <br /> Electronic Information: ❑ List❑ Map-Description: <br /> Specific Date Range of Information Requested: From j 7( to <br /> ENVIRONMENTAL FILE ADDRESS <br /> HEALTH DEPARTMENT ( p y 9 p <br /> FILES (Specific addresses only,address ranges will not be accepted) EHD USE ONLY <br /> Underground Tank(UST) Street# Street Name City <br /> CI Soup Site(LOP) r'n/ /r1� ❑CONSUMER <br /> Oth -Cleanup Site(Non-LOP) t 1 �D /t ic -- <br /> azardous Waste :.nt�� lA[1-t`I`tr�t j-1 Wt H� !Wt E]DAIRY <br /> Tie tl Permitted Facility 2 Lp M1 <br /> �A/boveground Tank <br /> 910 (Monitoring I Removal) ❑PWS <br /> iaz Idous Materials 3 <br /> pill/Release Response <br /> Solid Waste Facility/Vehicle 4 I hJ I IFir=ouu ry <br /> F]Food Facility <br /> ❑Pool/Spa - Sire Mrrmnnoe <br /> ❑Dairy 5 <br /> ❑Land Use Application Sites <br /> ❑Septic Pumper TrucB/ fi ❑HOUSING <br /> Yard I Chemical Tales. <br /> ❑Wastewater Treatment Plant ®2UPA <br /> Housing Abatement T AST I HM I HW <br /> Motel/Hotel <br /> ❑Chicken Ranch/Dog Kennel CUPA <br /> ❑Medical Waste Facility 8 UST <br /> U Tattoo/Body Pierdog C]SOLID WASTE <br /> Waste Tire g <br /> Complaint <br /> ❑Other(Please Specify): ❑ALcOUNTINe <br /> to <br /> ""BOXED AREA-EHD USE ONLY"' <br /> Am III -2' 1 , l .din e. r . m Q01 t vt e <br /> ❑ Records provided by Staff-PPR Complete. staff Name: EHD 4fi.afi <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />