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• Oct, h. 2016 1 : 3hFM No. 0007 P. 1 <br /> •� DAT D t@/ ED SA <br /> END LOG NUMBER <br /> tl NJOAQUINCOUNBUSH <br /> • ENVIRONMENTAL HEALTH DEPARTMENT <br /> •• OCT II c) 203 : 1868 East Hazelton Avenue, Stockton, CA 95205-8232 <br /> Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> 6 15 �7 <br /> EWRQNMENTAL PUBLIC RECORDS RELEASE APPLICATION <br /> APPLIC cur Lti✓LS2 Ll BUSINESS/AGENCY: t",EA�$ Ey;roame- 2; LNe- <br /> ADDRESS: IS3 Q S¢r �+—t CITY/STATEIZIP; gM" gLibA <br /> PHONE(1): (2);(510)90Cl'$(o�a1 FAXORE-MAIL: gr?� � �.('y�S. 6, <br /> Please allow 10 business days from date of application submittal for the records to bee avails la. <br /> Staff will con*thace <br /> nge an appointment date and time to review the requested records. <br /> ['CHECK BOX TO EXP39 F (AASH OFZ CHECK ONLY)-REQUEST PROCESSED IN 3,g/USIy/ESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> 1. List up to ten addresses ow. Select the type(s)of files from the Hat below by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(2091464-0136 or mail to the address Indicated above. 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 ill be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviews by the same applicant may require a$139 deposit priorto review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW; MONDAY-FRIDAY 8:00 AM•5:00PM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List❑ Map—Description: <br /> Specific Date Range of Information Requested: From 4VL to <br /> ENVIRONMENTAL <br /> HEALTH;FEESRTMENT FILE ADDRESS EHD USE ONLY <br /> UNOERORoutm TANK(UST) Stroet0 Street Name city <br /> NUP SUE(LOP) 1CyA( r-l'GLw,3WV�L ct �T l`j V� ❑COu6uMEq <br /> OTHER CLEANNP SITE(NDN-LOP) t 59 <br /> [� ROOUS WASTE <br /> p o.,qY <br /> TIERED PERMRTEOFACILITY E 41133 11(gl vi Q,�L, � L� t0l-I <br /> (�EOVEZRONNOTANK 1. 11 t1 { 7 6� <br /> [a'GST (MONITORING/REMO✓AL) ❑PwS <br /> HAZARDOUS MATERIALS <br /> �SPILI/RFiEABE RESPONSE <br /> F1 Sam WAM FACILITY I VEHICLE WATER CUMItt <br /> A <br /> El FooD FACE <br /> ❑POOOSPA SttE MI1Ywom <br /> ❑DAIRY E <br /> ❑LAND USE APPLICATION SUES <br /> ❑SEPTIC PUMPER TRUCK/ HoAIM <br /> 6 <br /> YARD/CHEMICAL TOILETS <br /> R) WASTEWATER TREATMENT PLANT <br /> GUPA <br /> ❑HOUSING ABATEMENT Z <br /> ❑MOTEUMOTEI <br /> lj CHICKEN RANCH/DOG KENNEL RCUPA-UST <br /> n MEDICAL WASTE FACILITY 0 <br /> TATTOMSDOY PIERCING <br /> ❑WAaYt TIRE ❑soLo wA UE <br /> e <br /> CDMPIAINi <br /> ❑OTHER(PLEASE SPECIFY): <br /> �Am'uN(INe <br /> 10 <br /> "'BOXED AREA-EHD USE ONLY"' <br /> d Records provided by Staff-PPR Complete. STUN Nemo: <br /> Received Time Oct. 5. 2016 . 1 : 33PM No, 0100 <br />