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SAN�JOAQUIN �E�E« Dronmental Health Department <br /> �. <br /> —COUNTY— WV PUBLIC RECORDS RELEASE APPLICATION <br /> • Greatness grows here,EWRONMENTALHEALTH 37y 75 <br /> EHD LOC, NUMBER: <br /> APPLICANT: 3je CI S C BUSINESS/AGENCY: C f C. <br /> ADDRESS: CITYISTATEIZIP: (/ <br /> PHONE(1): P4iONE(2): FAX OR E-MAIL: <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you tearrange anflo , <br /> itment date and time to review the requested records. <br /> SIGNATURE OF APPLICANT ��;,E� - DATE // <br /> 1. List up to ten addresses in th a below. dress ranges WILL NOT be accepted. Select the type s)of files from the <br /> list below by checking the appropriate box(es). At least one file type MUST be selected. Fax to(2091464-0138,mail to the <br /> address indicated below,or email to infolaDsicehd.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. <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$152 deposit prior to 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 /> Speck Date Range of Information Requested: From to <br /> ENVIRONMENTAL FILE ADDRESS <br /> HEALTH DEPARTMENT y 9 p ) EHD USE ONLY <br /> FILES (Specific addresses only,address ranges will not be acre ted <br /> l�Underground Tank(UST) Street# Street Name City <br /> Cleanup Site(LOP) /V.A-hne('Atih PA 0 r ❑oor+SUUEa <br /> • <br /> d6as�Other Cleanup Site(Nan-LOP) �) <br /> _ffHarardous Waste DAIRY <br /> Tiered Permitted Facility R <br /> Aboveground Tank <br /> ST (Monitoring/Removal) /6"g'� �Qk, 5 <br /> azardous Materials a � t/l <br /> Spill!Release Response 1 <br /> Solid Waste Facility/Vehicle 41(q h I rt�rr�n We.Ou4� <br /> E]Food Facility ` n,V <br /> ❑Pool/Spa sire mmoRTIOe <br /> ❑Dairy 5 <br /> ❑Land Use Appllcadon Sites <br /> Septic Pumper Truck/ <br /> 6 <br /> Yard 7 Chemical Toilets <br /> ❑Wastewater Treatment Plant COPA <br /> ❑Housing Abatement T AST/HM/HW <br /> ❑Motel/Hotel <br /> ❑chicken Ranch/Dog Kennel MkUPA <br /> 8 <br /> Medical Waste Facility UST <br /> ❑Talloo/6otly Piercing p Scam WAM <br /> ❑Waste Tire e <br /> ❑Complaint <br /> Fj Other(Please Specify): [I AccouHrma <br /> a <br /> "BOXED AREA•EHD USE ONLY*'" <br /> • <br /> ❑ Records provided by Staff-PPR Complete. staff Name: EHD 4846 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />