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iLIVED <br />MAY 15 2017 <br />ENVIRONMENTAL HEALTH <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Tel phone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />PUBLIC RECORDS RELEASE APPLICATION <br />EHD LOG NUMBER <br />e(v j q 0 <br />APPLICANT: �\'? I"( . <br />.TBUSINESS/AGENCY: <br />ADDRESS: 4-9-79 fad-, 1 <br />!". CITY/STATE/ZIP: <br />PHONE (1): a ni - P <br />PHONE�'17- `ad ?- r ( - FAX OR E-MAIL: <br />ness days from date of application submittal for the records to be available. <br />Please allow 10J,�tl <br />Staff will contau <br />o arrange an appointment date and time to review the requested records. <br />❑ CHECK BOX TO EXPEQUES , $1 ' FEE (CASH OR CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT <br />-• DATEf ll rl*'` 7 <br />1. List up to ten addresses ith <br />space below. Select the type(s) of files from the list below by checking the appropriate <br />box(es). At least one file typ <br />MUST be selected. Fax to (209) 464-0138 or mail to the address indicated above. Address <br />ranges will not be accepted. <br />pplications received after 3:00 pm will be processed the next business day. <br />2. For assistance in identifying <br />a nature and content of EHD records, please contact EHD at the number noted above. <br />3. The EHD will notify the applic <br />nt if any EHD files exist. An appointment for review will be confirmed approximately ten (10) <br />days after receipt of applicati <br />n. The files will be held for a maximum of five business days for review. Appointments <br />should be scheduled accordi <br />gly. <br />4. Any file not returned in the sa <br />a condition as released will be reorganized by EHD staff at the expense of the applicant. <br />Future file reviews by the sam <br />applicant may require a $139 deposit prior to review. <br />WELL AND SEPTIC PERMIT REC <br />RDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:OOPM (EXCLUDING HOLIDAYS) <br />Electronic Information: ❑ L st ❑ Map — Description: <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FILES <br />FILE ADDRESS <br />EHD USE ONLY <br />\_UNDERGROUND TANK (UST) <br />street # <br />Street Name <br />City <br />, <br />I CONSUMER <br />Ly� CLEANUP SITE (LOP) <br />OTHER CLEANUP SITE (NON -L <br />1 <br />-°Z� <br />1 <br />HAZARDOUS WASTE <br />,TIERED PERMITTED FACILITY <br />2 <br />/ <br />❑ UAIRY <br />ABOVEGROUND TANK <br />UST (MONITORING/ REMOVAL) <br />HAZARDOUS MATERIALS <br />XSPILURELEASE RESPONSE <br />SOLID WASTE FACILITY /VEHICLE <br />y� El PWS <br />° <br />4 <br />/9 ^� <br />WATER QUALITY <br />FOOD FACILITY <br />tU(SITE MITIGATION <br />POOL / SPA <br />DAIRY <br />5 <br />LAND USE APPLICATION SITES <br />F] SEPTIC PUMPER TRUCK / <br />6 <br />HOUSING <br />YARD / CHEMICAL TOILETS <br />❑ WASTEWATER TREATMENT PLANT <br />CUPA <br />HOUSING ABATEMENT <br />T <br />MOTEUHOTEL <br />8 <br />CUPA - UST <br />❑ CHICKEN RANCH / DOG KENNEL <br />MEDICAL WASTE FACILITY <br />TATTOO/BODY PIERCING <br />SOLID WASTE <br />WASTE TIRE <br />9 <br />COMPLAINT <br />❑ OTHER(PLEASE SPECIFY): <br />❑ ACCOUNTING <br />10 <br />