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AN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> OCT 18 ,2017 1868 East Hazelton Avenue, Stockton, CA b:www.sjgo'v.org/ehd Y70 <br /> Telephone:(209)488-3420 Fax: (209)464.0138 Web:wwW.sjgov.org/ehd137 <br /> f ENVIRONMENTAL HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> .PPLICANT: �/� �(\�j �1rCt BUSINESSIAGENCY: y <br /> ADDRESS: CITYISTATE1ZIP: ; of Pp <br /> PHONE(1):( o I- 'Y �-01 � PHONE(2): FAX OR E-MAIL '�© g k o <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 /> WOM, 00 1kx6tfe / � fSR1� "��� .�s� <br /> xrY „ <br /> SIGNATURE OF APPLICANT <br /> _ � K-rr DATE <br /> 1. List un to ten addresses m apac low. elect t to pe(s) Iles from the list below by checking the ppropriate <br /> box(es). At least one file type MUS-We selected. Fa to 209 8 or mail to the address Indicated a ove 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. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:D0 AMw;00PM(FXCLUDING HOLIDAYS) f <br /> Electronic Information: ❑ List❑ Map-Description; <br /> Spec Date Range of Information Requested: From _ \ _ to 0\~7 <br /> ' rM FILE ADDRESS <br /> AR <br /> 'I EHD USE ONLY <br /> ❑UNDERGROUNDTANK(LIST) street,# Street Name city j <br /> CLEANUP SITE(LOP) ` N CONSUMER <br /> OTHIM CLP1WOP SUE(NON-LOP) t 1553 Novw. 4 �A, <br /> '❑HAZARDOUS WASTE ��'I,11/9 DAIW <br /> ❑TIERED PERMITTED FACILDY <br /> ❑ASGvsDROUND TAM <br /> ❑UST (MoMTomaI REuovA) ❑PWS <br /> ❑HAZARDOUS MATE S rej R n-g P (at r C.tSi"�d <br /> ❑SPWiRELEASE RESPONSE /O/ I ❑WA�riUNRY <br /> D SOuo WASTE FACKM I VEHICLE y 17 <br /> V000 FAO un <br /> ❑POOL I SPA ❑8D8MmaAmaN <br /> ❑DNRY S <br /> ❑LAND USE APPLICATION SDt:S <br /> I--T <br /> J 13 HOMING SEPTIC PUMPERTRVCKf S <br /> YARD I CHEnaCAL TOILETS <br /> ❑WASTEWATER TREAT SNT PI-ANT [jCUPA <br /> ❑HoUSIN6 ABATEMENT <br /> �]MoteL/Hare� <br /> [�CHICIsN RANCH I Doc IQNNEL ❑CUPA-UST <br /> 8 <br /> ❑MEDICAL WASIE FACLfTY <br /> ❑TATTOClaODY PI5R NG f]SOCIO WAerE <br /> ❑WASTE TIRE S <br /> iJ coMPLNNT <br /> ❑OTHER(PLEASE SPP cx): Acc*R NG <br /> to <br /> p '—ROXHD AREA,EHD USE ONLY— <br /> ❑ Records provided by Staff-PPR Complete,sen Nmn <br /> Received Time%c t. 18. '2011�10: 22ANFN0. 2473 <br />