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RESEIVECJ i <br />SAN JO A "M 6 2018 Environmental Health Department <br />C, 0 �j N TY PUBLIC RECORDS RELEASE APPLICATION <br />EAfV M NMENTAL <br />NI <br />PEP"TISERVIbift SUBMIT BY EMAIL <br />EHD LOG NUMBER: <br />APPLICANT: r tA r I, f f j%iv BUSINESSIAGENCY: <br />ff <br />ADDRESS: CITY/STATErZIP <br />PHONE (1): - -Z27 21C PHONE (2): _ FAX OR E-MAIL; !XJ • fl1/Mt <br />lease a nut -40 busiss s from date of application submittal for the records to be available. <br />Staff will contact yo to n n ppolntment date and time to review the reques recSO s. <br />SIGNATURE OF APPLICANTDATE -- <br />1. List up to ten addaW,es In the ejace below. Addr 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 (209) 464M38, mail to the <br />address indicated h2low, or email to info0s d c m. , 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 flies exist. An appointment for review will be confirmed approximately ton (10) <br />days after receipt of application. The files will be hold 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 $162 deposit prior to review. <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 />.�..,�. 1. <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FILES <br />{Specific addressee <br />FELE ADDRESS <br />only, address rangers will riot <br />be emepted) <br />EHD USE Q! !Y <br />nderground Tank (UST) <br />street 0 <br />Street Name <br />C <br />Cleanup Site (LOP)T <br />1 <br />a n <br />(� I <br />o <br />other Cisanup Site (Non -LOP) <br />I <br />❑ Hazardous Waste <br />Tiered Permitted Facility <br />Z <br />1301 <br />,r, <br />' �/ } <br />O Aboveground Tank <br />/ <br />1-.4 n G <br />v " <br />s <br />4a <br />!n <br />(,L LA <br />N <br />i ! 1 <br />T� <br />y <br />❑ UST (monitoring/ Removal) <br />Hazardous Materials <br />0 <br />spill I Release Response <br />solid We.te Fadlky, / Vehicle <br />❑ WRYER QMM <br />s <br />W Tt4 Into— <br />'li <br />Rood Facility <br />D <br />El Pool I spa <br />E Dairy <br />s <br />}�� <br />( / _+� /L+w <br />`�/ �: ,T r <br />1 �. ^ <br />sj/ ('�j/� aa✓/ <br />❑ p+nE M#Y14AYIDN <br />❑ Land Use Application Sites <br />6 <br />' y1� /7 <br />1 ,A %� I <br />/ �/ <br />�..... <br />13 Hous— <br />[� Septic Pumper Truk / <br />Yard / Chemical Toilets <br />❑ Wastewater Treatment Plant— <br />[] Housing Abatement <br />7 <br />,�./t �% <br />' " Q <br />[3 CUPA <br />ta"� <br />L) <br />AST/HM/HW <br />❑ Motel/Hotel <br />Chicken Ranch / Dog KennelR <br />e <br />N <br />13CUPA <br />Q Medical Waste Facility <br />y <br />UST <br />TottooBody Piercing <br />- <br />C] Waste Tire <br />Complaint <br />I "I Other (Please Specify). <br />0 <br />10 <br />Name: <br />1868 E. Hazelton Avenue ( Stockton, California 95205 1 T 209 4.68-3420 1 F 209 464-0138 1 www <br />