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RECEIVE® <br /> SAN )OAQ I C Environmental Health Department <br /> • �� PUBLIC RECORDS RELEASE APPLICATION <br /> PEIlMfTISEfZaI'1cE9 <br /> EHD TL-O� G NUMBER: �7 Pill <br /> (h <br /> APPLICANT: 1 �tl Ct LSQ�A. BUSINESS/AGENCY:�1P 1,[. <br /> ADDRESS: 2:z5i {� Q . CITY/STATEIZIP:�tLnCl <br /> PHONE(1): PHONE(2): FAX OR EE-h1'A'I'L'- <br /> Please allow 10 business days from date of application submittal for the records to be available. IYl <br /> Staff will cogta4 ro to arran a an-appointment date and time to review the request Fecor s. <br /> SIGNATURE OF APPLICANT ( 'TV V WSIOL_CP DATE 10( (rj <br /> 1. List up to ten addresses in the space below. Address ranges WIL NOT be accepted. Select the types)of files from the <br /> Fist 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 infoOsicehd.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. a <br /> 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. 1 <br /> Future file reviews by the same applicant may require a$152 deposit prior to review. 1 1 <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 (Specific y 9 ) EHD USE ONLY <br /> FILES S ecific addresses only,address ranges w(II not be accepted <br /> Underground Tank(UST) Street# Street Name city __ <br /> Cleanup Site(LOP) t E,' (- M-IL hlVD r p��""`° <br /> • Other Cleanup Site(Non-LOP) / ��) I 44-(-V- w.F-I <br /> � � � C __. <br /> Hazardous Waste ❑Dunv <br /> Tiered Perminad Facility 2 � <br /> Aboveground Tank <br /> .�UST (Monitoring/Removal) i/�10 ❑PWS <br /> r 3 1 <br /> 14l Hazardous Matedals <br /> D9Spill/Release Response q 21 I�I <br /> .Y." WeTsa Duum <br /> ❑Solid Waste Facility I Vehicle 4 �^�/ <br /> ❑Food Facility V4 is <br /> Srta IXnunoN <br /> ❑POOI I Spa <br /> Dairy S IG <br /> ❑Land Use Application Sites I� I Y 0 Houswa <br /> ❑Septic Pumper Track I <br /> Yard/Chemical Toilets VVVV <br /> n Wastewater Treatment Plant MICUPA <br /> Housing Abatement T AST I HM I HW <br /> ❑Motel/Hotel <br /> Chicken Ranch/Dog Kennel CUPA <br /> g UST <br /> ❑Medical Waste Facility <br /> TaltoolSody Piercing 0 soup W vI,m <br /> Waste Tire g <br /> ❑complaint <br /> ❑other(Please Specify): C]ACCOUNTING <br /> tg <br /> "BOXED AREA-EHD USE ONLY-* <br /> q'�(' - Lr ale„ CU /M ��tfG 1�v PR,QI, ` ann J rOCC in frin kT I-f- MR <br /> • ❑ Records provided b Staff-PPR Complete,staff name: eII <br /> 1868 E. Hazelton Avenue I Stockton.. California 952051 T 209 468-342201 F 209 464-0138 1 www.sicehd.com <br />