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PECEIVED a <br /> 5 <br /> � �a Envirc�nryientai Health Department <br /> WJOAQllI i J, <br /> COUNTY---a t�tTe .,� PUBLIC RECORDS RELEASE APPLICATION <br /> Grimness grows be <br /> rFt�NVIl2QNMENT..; <br /> PERMIT/SE pYEMAIL + �j <br /> EHD LOG NUMBER: l <br /> g z <br /> APPLICANT: ba <br /> u/1-0 QAI'C, BUSINESSIAGENCY: <br /> ADDRESS: 1810 its. ieCITYlSTATEJZIP: XkAt, CA q9 ;UE <br /> PHONE(1): PHONE(2): FAX OR E-MAIL: f sta rs <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to TaT Tanan appointment date and time to review the requested records. r <br /> SIGNATURE OF APPLICANTj- •pj_111 DATES J� <br /> 1. List up to ten addresses'tai the space below. Address ranges WILL NOT be accepted. Select the types)of files from the 1 <br /> list below by checking he appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138,mail to the t <br /> address indicated below,or email to info@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. r <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 2 <br /> should be scheduled accordingly. <br /> k <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 /> 2� <br /> Future file reviews by the same applicant may require a$152 deposit prior to review. I <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> f <br /> Electronic Information: ❑ List❑ Map—Description: 4 <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 /> Underground Tank(UST) Street# Street Name City 5 <br /> Cleanup Site(LOP) j t--�. I 1 [i CONSUMER <br /> 1 `v <br /> Other Cleanup Site(Non-LOP) <br /> Hazardous Waste i �L 19"DAIRY <br /> ©Tiered Permitted Facility rz a� , <br /> Aboveground Tank ShAb2zjk <br /> UST (Monitoring/Removal) PWS <br /> 4 Hazardous Materials 3L <br /> �a'f _ t�z���i T' j _f\. bbl gr, <br /> Spill/Release Response <br /> Solid Waste Facility/Vehicle 4 G,rwi u� I ✓. 'WATER QUALITY <br /> Food Facility / !( f7� f S(U ✓�n, ` 1C t <br /> Pool/Spa -- .t� SiTa MITIGATION § <br /> Dairy ' li✓ti• ` <br /> Land Use Application Sites S ' <br /> H <br /> Septic Pumper Truck/ a �'�i�" ; � [g/HOUSING <br /> I; <br /> Yard/Chemical Toilets <br /> Wastewater Treatment Plant !44 p� T a p'CUPA <br /> Housing Abatement 7 _ �{iv,`{sh� p AST/HM/HW <br /> ❑Motel/Hotel (J�C S, '� �' y� - �'1 r'�✓ v' 7 <br /> Chicken Ranch/Dog Kennel I p. UPA <br /> g f <br /> Medical Waste Facility UST l <br /> ❑Tattoo/Body Piercing u <br /> Cb souowisr= II <br /> Waste The g )PY �\ <br /> Complaint tI 'v <br /> ❑Other(Please Specify): ❑10 AccOUNTNG I <br /> p <br /> 'BOXED AREA-EHD USE ONLY' <br /> r, L <br /> ( 't `�; f`•1.. Lam- JJ i •\ C '-��, �,r'';� r .� tt i tint f• :� <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: EHD41-06 <br /> II <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 wWw.sjcehd.com <br /> �I <br />