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% <br /> SAN JOA U I h� '�til I °<hfunrneriit la-alth Department <br /> C C7 U NI T Y - - �40 0 9 20%, PUBLIC RECORDS RELEASE APPLICATION <br /> �>a�IF. All. i <br /> EHD LOG NUMBER: <br /> APPLICANT: �� ,�S' BUSINESS/AGENCY: Ie- <br /> ADDRESS: CITYIST'ATE21P: -- <br /> PHONE(1): _JM. 3-A3--qllla PHONE(2)= oPoV y/ 37 FAX OR E-MAIL: 3f 5 ,'r1`6 ,--"r/, <br /> Please allow 10 business days from d f application submittal for the records to be available. C, <br /> Staff will contact you to arrange an t9lie,4 late and time to review the requested records. <br /> SIGNATURE OF APPLICANT 4% •- DATES'- ' -/e <br /> 1. List up to ten addresses In the space below. Add s nges WILL NOT be accepted. Select the type(s) of files from the <br /> list below by checking the appropriate box(es). east one file type MUST be selected. Fax to(209)464-0138,mail to the <br /> address indicated below,or email to info0sicehd.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 /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> Electronic information: ❑ List Imap—Description: <br /> Specific Date Range of Information Requested: From j �j r __ to <br /> ENVIRONMENTAL FILE ADDRESS <br /> HEALTH DEPARTMENT ( p Y 9 accepted) EHD USE ONLY <br /> FILES S eclfic addresses only,address ranges will not be acne ted <br /> Underground Tank(UST) Street# Street Name City <br /> leanup Site(LOP) I i E)CDNSULER <br /> other Cleanup Site(Non-LOP) <br /> 1KHazardous Waste <br /> o DAIRY <br /> Tiered Permitted Facility T u <br /> Aboveground Tank '1 •(� (iv� �' _ <br /> UST (Monitoring/Removal) <br /> ZHazaSpill <br /> rdous Maleriats <br /> Spill/Release Response — --- -- <br /> Solid Waste Facility!Vehicle 4 Q WATER quem <br /> Food Facility <br /> ®Pool t Spa E]SITE MMIGAT10N <br /> Dairy 6 <br /> ErLend Use Application Slips <br /> E7'13eptic Pumper Truck/ Q"HousiNc <br /> 9 <br /> Yard 1 Chemical Toilets <br /> Wastewater Treatment Plant [j CUPA <br /> gHousing Abatement 7 AST l HM 1 HW <br /> emotel/Holel <br /> Chicken Ranch I Dog Kennel ❑CUPA <br /> E <br /> Medical Waste FacilityUST <br /> TattoolBody Piercing <br /> p ouo WASTE, <br /> Waste Tire y <br /> 9Complalnt <br /> �j F-1 Other(Please Specify): r,(I IT 0 AccouNttNc <br /> —BOXED AREA-EHD USE ONLY* <br /> �} 6 <br /> - Ll��i c.\�f r` .(...,t^�-t/� -. ^�c,�a-'� [.'(- a• � x vim, t�'=:....... <br /> - r�t <br /> ❑ Records provided by Staff-PPR Complete. staff Name: T^ EHD 4&06 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 458-3420 F 209 454-0138 1 vAvw.sjcehd.com <br />