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p�1N <br /> 2 <br /> ° c SAN J Q AQ U I N Environmental Health Department <br /> COUNTY PUBLIC RECORDS RELEASE APPLICATION <br /> `'q[ ¢ Greatness grows here. <br /> SUBMIT BY EMAIL <br /> EHD LOG NUMBER: <br /> APPLICANT: BUSINESS/AGENCY: <br /> ADDRESS: CITY/STATE/ZIP: <br /> PHONE (1): PHONE(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 to arrange an appointment date and time to review the requested records. <br /> SIGNATURE OF APPLICANT 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 ehdfilereview(a)sjgov.org. Applications received after 3:00 pm will be processed the <br /> next 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 FILE ADDRESS <br /> HEALTH DEPARTMENT ( ponly, 9 p <br /> FILES S ecific addresses address ranges will not be accepted) EHD USE ONLY <br /> ❑ Underground Tank Street# Street Name City <br /> (UST)Cleanup Site ❑CONSUMER <br /> L! OP) 1 <br /> ❑Other Cleanup Site <br /> Non-LOP ❑DAIRY <br /> ❑ Hazardous Waste 2 <br /> ❑Tiered Permitted Facility <br /> ❑Aboveground Tank ❑PWS <br /> ❑ UST (Monitoring/ 3 <br /> Removal <br /> ❑ Hazardous Materials <br /> El Spill/Release ❑WATER QUALITY <br /> a <br /> Response <br /> ❑Solid Waste Facility/ <br /> ❑SITE MITIGATION <br /> Vehicle <br /> s <br /> ❑ Food Facility <br /> ❑ Pool/Spa <br /> ❑ Da <br /> 01 ❑HOUSING <br /> ❑ Land Use Application e <br /> Sites <br /> ❑Septic Pumper Truck/ ❑CUPA <br /> Yard/Chemical Toilets 7 AST/HM/HW <br /> ❑Wastewater Treatment <br /> Plant ❑CUPA <br /> ❑ Housing Abatement s UST <br /> ❑ Motel/Hotel <br /> ❑Chicken Ranch/Dog ❑SOLID WASTE <br /> Kennel 9 <br /> ❑ Medical Waste Facility <br /> ❑Tattoo/Body Piercing <br /> ❑Waste Tire ❑ACCOUNTING <br /> ❑Complaint 10 <br /> ❑Other(Please Specify): <br /> ***BOXED AREA-EHD USE ONLY*** <br /> ❑ Records provided by Staff-PPR Complete. staff Name: EHD 4e-06 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br />