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DAT !•ICE EIV `0 D SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> F"IrB 'ENVIRONMENTAL HEALTH DEPARTME <br /> Z�9� ..,38 East Hazelton Avenue, Stockton, CA 95205--z32 <br /> Tel phone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> E .PERM.IMERLHEALTti IXES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: 210 WK BUSINESS/AGENCY: <br /> ADDRESS: L '�, �� CITY/STATE/ZIP: ! <br /> PHONE (1): 'SIU 'i(, _C> It PHONE (2): -51U31(-, (,��?Q FAXOR E-MAIL: �UNrfK�'"L3 <br /> Please allow 10 usiness days from date of application submittal for the records to be available. j3G t,i�;#j »nu <br /> Staff will contac you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXP7anyEHD <br /> 9 FEE ASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> 1. List up to ten addresses spade below. Select the type(s) of files from the list below by checking the appr pria e <br /> box(es). At least one fileUST be selected. Fax to (209)464-0138 or mail to the address indicated above. Address <br /> ranges will not be acceptplications received after 3:00 pm will be processed the next business day. <br /> 2. For assistance in identifye nature and content of EHD records, please contact EHD at the number noted above. <br /> 3. The EHD will notify the at if any EHD files exist. An appointment for review will be confirmed approximately ten (10) <br /> days after receipt of appl . The files will be held for a maximum of five business days for review. Appointments <br /> should be scheduled accly.4. Any file not returned in the condition as released will be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviews by the applicant may require a$139 deposit prior to review. <br /> WELL AND SEPTIC PERMIT DS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ ist ❑ Map—Description: <br /> Specific Date Range of Inform tion Requested: From to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESS <br /> FILES EHD USE ONLY <br /> UNDERGROUND TANK(UST) treet# Street Name City p <br /> CLEANUP SITE(LOP) ` � � � � �� � ._ `/ ❑CONSUMER <br /> ,-y5'OTHER CLEANUP SITE(NON-L'Pi <br /> '%HAZARDOUS WASTE '} <br /> 'Y ��J E]DAIRY <br /> F]TIERED PERMITTED FACILITY 2 <br /> ABOVEGROUND TANK <br /> E6.UST (MONITORING/REMOVAL) ❑PWS <br /> HAZARDOUS MATERIALS 3 <br /> %—SPILURELEASE RESPONSE <br /> WATER QUALITY <br /> SOLID WASTE FACILITY/VEHICLE 4 <br /> FOOD FACILITY <br /> F]POOL/SPA 56 SITE MITIGATION <br /> F DAIRY 5 <br /> LAND USE APPLICATION SITES <br /> SEPTIC PUMPER TRUCK/ 6 E]HOUSING <br /> YARD/CHEMICAL TOILETS <br /> WASTEWATER TREATMENT PLANT Rf CUPA <br /> HOUSING ABATEMENT 7 <br /> MOTEL/HOTEL <br /> CHICKEN RANCH/DOG KENNEL I 'CUPA-UST <br /> 8 <br /> MEDICAL WASTE FACILITY <br /> ❑TATTOO/BODY PIERCING Lj <br /> SOLID WASTE <br /> ❑WASTE TIRE 9 <br /> COMPLAINT <br /> ❑OTHER(PLEASE SPECIFY): E]ACCOUNTING <br /> 10 <br /> —BOXED AREA-EHD USE ONLY"" <br /> If FecorcKs provid by Staff-PP C mplete. Staff Name: <br /> EHD 46-06 <br />