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SANJOAQUIN Environmental Health Department <br /> COUNT"( - --- PUBLIC RECORDS RELEASE APPLICATION <br /> EHD LOCA NUMBER: <br /> APPLICANT: �. ` BUSINESS/AGENCY: L^ <br /> ADDRESS: CITY/STATE/ZIP: 'S7X)C_X C Ar <br /> PHONE (1)(• PHONE (2): FAX OR E-MAIL: <br /> Please allow 0 Musiness days from date of application submittal for the records to be availabl Y , YT <br /> Staff will contact u to r ga. ointm nt date and time to review the requested records.y <br /> SIGNATURE OF APPLICANT g DATE <br /> 1. List up to ten addresses in the space below. Address 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)464-0138, mail to the <br /> address indicated below, or email to info@sicehd.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 /> SEPTIC AND WELL PERMITS ARE AVAILABLE FOR REVIEW ONLINE AT: https://www.sjgov.org/department/envhealth/public-records <br /> Electronic Information: ❑ List❑ Map— Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL I <br /> LE ADDRESS <br /> HEALTH DEPARTMENT <br /> FILES (Specific addresses only, address ranges will not be accepted) EHD USE ONLY <br /> ❑ Underground Tank(UST) Street# Street Name City <br /> Cleanu Site LOP) ❑CONSUMER <br /> 1 <br /> ❑Other Cleanup_Site(Non-LOP) v� <br /> ❑ Hazardous Waste ❑ <br /> HAIRY <br /> ❑Tiered Permitted Facility 2 <br /> ❑Aboveground Tank <br /> ❑ UST (Monitoring/Removal) ❑PWS <br /> El Hazardous Materials 3 <br /> ❑SpiII/Release Response <br /> ❑WATER QUALITY <br /> ❑Solid Waste Facility/Vehicle 4 <br /> ❑ Food Facility <br /> ❑ <br /> Pool/Spa ❑SITE MITIGATION <br /> ❑ Dairy 5 <br /> ❑Land Use Appplicetion Sites. <br /> ❑Septic Pumper Truck/ 6 ❑HOUSING <br /> Yard/Chemical Toilets <br /> ❑Wastewater Treatment Plant ❑CUPA <br /> ❑ Housing Abatement 7 AST/HM/HW <br /> ❑Motel/Hotel <br /> ❑Chicken Ranch/Dog.Kennel ❑CUPA <br /> ❑Medical Waste Facility $ UST <br /> ❑Tattoo/Body Piercing ❑SOLID WASTE <br /> ❑Waste Tire g <br /> ❑Complaint <br /> ❑ Other(Please Specifyl ❑AccoUNTING <br /> 10 <br /> —BOXED AREA-EHD USE ONLY— <br /> El Records provided by Staff-PPR Complete. Staff Name: EHD 48-06 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br />