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SANLIOAQUIN Wironmental Health Department <br /> --COU N TY-- MAP O 7 2018 PUBLIC RECORDS RELEASE APPLICATION <br /> q, Greotness crows here ENVIRONLTH <br /> PERMIMENTALHEAEHD LOG NUMBER: <br /> •APPLICANT: G Zi BUSINESS/AGENCY: <br /> ADDRESS: CITY/STATE/ZIP: ST �,;.r <br /> PHONE(1): ��,?j/�]7 PHONE(2)- _FAXORE-MAIL: <br /> U1�J Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will co you to arrange app tment date and time to review the requested records. <br /> SIGNATURE OFAPPLICAg�j� ( DATE �� <br /> 1. List up to ten addresses the space below. Ad r 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 infoidisicehd.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. 3/�� <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 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 /> Cleanup Site(LOP) tM r r✓lt ❑CONSUMER <br /> Other Cleanup Site(Non-LOP) t <br /> ❑ Hazardous Waste l.{M <br /> DAIRY <br /> ❑Tiered Permitted Facility 2 �1/J a / f%%%`�/�r�vIN ✓f vl�� N <br /> ❑Aboveground Tank <br /> ry <br /> F] HM N UST (Monitoring I Removal) pPWS <br /> d- <br /> 3 <br /> ®Hazardous Materials <br /> ❑Spill/Release Response p 1n, <br /> ❑Solid Waste Facility/Vehicle 4OJIp I l V WAreR QUALITY <br /> ❑ Food Facility <br /> ❑Pool/Spa ISE MIRIGNTION <br /> F� Dairy 5 <br /> Land Use Application Sites <br /> Septic Pumper Truck/ []HOUSING <br /> 6 <br /> Yard/Chemical Toilets <br /> ❑Wastewater Treatment Plant COPA <br /> Housing Abatement T ASTI HM I HW <br /> ❑ Motel/Hotel <br /> ❑Chicken Ranch/Dog Kennel ❑CUPA <br /> g <br /> ❑Medical Waste Facility UST <br /> F-1 TattooBody Piercing L]SOLID WASTE <br /> Waste Tire g <br /> ❑Complaint <br /> ❑Other(Please Specify): ❑ACCOUNTING <br /> io <br /> ***BOXED AREA-EHD USE ONLY*** <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: EHD 4BOG <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />