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�—<—�—A" j Qi-M�Mv � <br /> nm8Hea8th Department <br /> [OUN PUBLIC RDS RELEASE APPLICATION <br /> ` <br /> 1 <br /> ,v w mum <br /> EHD LOG NUMBER: <br /> ADDRESS: CITYISTATEIZIP: <br /> PHONE (1): PHONE(2): FAX OR E-MAIC-" <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contajetv., '�'to arrange an appointment date and time to review the requested records. <br /> SIGNATURE OF APPLICANT <br /> 1. List up to ten addresses in/tg�space below. Address ranges WILL NOT be accepted. Select the type(s) of files from the <br /> t below by checking the'appropriate box(es). At least one file type MUST be selected. Fax to ("jJ641W38Aa&tQ-f11e-- <br /> address indicated below, orernailto info(a)sicehd.com. Applications received after 3:00 prn will rjjDctedUff Y <br /> business day. Lu <br /> 2. For assistance in identifying the nature and content of EHD records, please contact EHD at the number noted below. <br /> 3. The EHDwill notify the applicant ifany EHDfiles exist. Anappointment for review will boconfirmed approximately ten (i0 � <br /> days after receipt ofapplication. The files will boheld for amaximum offive business days for review. Appointments <br /> should boscheduled 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 /> / <br /> SEPTIC AND WELL PERMITS ARE AVAILABLE FOR REVIEW ONLINE AT: httpx:0vmww.sjgov.ong/dopudmonUenvhea|tNpub|io'exordo ^ <br /> Electronic information: [I List D Nqap— Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES (Specific addresses only,address ranges will not be accepted) EHD USE ONLY <br /> RNI Underground Tank(UST) Street# Street Name City <br /> Cleanup Site(LOP M16ONSUMER <br /> XOther Cleanup Site(Non-LOP) <br /> Ste <br /> Hazardous Wa 141 <br /> boveground Tank <br /> UST (Monitoring/Removal) [SpPWS <br /> Hazardous Material <br /> Spill/Release Resnons <br /> 7-1 gAATER QUALITY <br /> Dairy 5 <br /> Land Use Application Sites <br /> HOUSING <br /> Septic Pumper Truck 6 <br /> Yard/Chemical Toilets <br /> Wastewater Treatment Plan UPA <br /> Housing Abatemen 7 AST/HM I HW <br /> 8 LIST <br /> [9'SOLII)WASTE <br /> Waste Tire 9 C/V <br /> (Please Specify) 10 V ACCOUNTING <br /> ***BOXED AREA-EHD USE ONLY— <br /> El Records provided by Staff-PPR Complete. StaffName: EHD 48-06 <br />