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u oP}" jI SKJOAQUIN RECENfi rl-onmental Health Department <br /> y' P 'r —COUNTY— NOV ' 7 ZU,/ PUBLIC RECORDS RELEASE APPLICATION <br /> C' <br /> yrrrQa� Greatness grows here. MARI- 3RIA, 87543 <br /> EwRoNMEN kHEAtTH EHD LOG NUMBER: <br /> 87543 <br /> BETTINA BERGREN BUSINESS/AGENCY: STATE BOARD OF EQUALIZATION <br /> ADDRESS: 3321 POWER INN RD,STE 210 CITY/STATE/ZIP: SACRAMENTO, CA 95826-3889 <br /> PHONE (1): (916)227-6716 PHONE (2): FAX OR E-MAIL: (916)227-6706 <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 /> SIGNATURE OF APPLICANT PROCESSED VIA MAIL BY STAFF. DOM M DATE NOVEMBER 17, 2017 <br /> 1. List un 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(asicehd.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. 11 /� <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) l <br /> Electronic Information: ❑ List❑ Map— Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL FILE ADDRESS <br /> HEALTH DEPARTMENT <br /> FILES (Specific addresses only,address ranges will not be accepted) EHD USE ONLY <br /> F] Underground Tank(UST) Street# Street Name City <br /> Cleanup Site(LOP) El CONSUMER <br /> Other Cleanup Site(Non-LOP) <br /> Hazardous waste --- <br /> DAIRY <br /> Tieretl Permitted Facility 2 <br /> ❑Aboveground Tank <br /> UST (Monitoring/Removal) ❑PWS <br /> Hazardous Materials 3 <br /> Spill/Release Response <br /> n Solid Waste Facility/Vehicle 4 ❑WATER QUALITY <br /> ® Food Facility <br /> Pool/Spa Sire Mlncanox <br /> Dairy 8 <br /> F1 Land Use Application Sites <br /> F1 Septic Pumper Truck/ ❑HOUSING <br /> 8 <br /> Yard/Chemical Toilets <br /> Wastewater Treatment Plant [I CUPA <br /> F1 Housing Abatement 'r AST/HM/HW <br /> ❑Motel/Hotel <br /> Chicken Ranch/Dog Kennel ❑CUPA <br /> 8 <br /> Medical Waste Facility LIST <br /> Tattoo/Body Piercing <br /> Waste Tire e E]SOLID Wg3re <br /> Complaint <br /> ®Other(Please Specify): ®AccoUNTINa <br /> SEE ATTACHED REQUEST fp <br /> ***BOXED AREA-EHD USE ONLY*** <br /> 7 1117/2017- ALLED APPLICANT TO CONFIRM RECEIPT OF PRRA. DOM M <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: EHD 4e-06 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />