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S�4�_JOAQ onm. 6 eafth Department <br />--COUNTY---E/JyQ 8' <br />201 PUBLIC R SAPPLICATION <br />F1i'�t l> �'+�... <br />��wm�uWAM EHD LOG NUMB <br />& <br />._......�sem ER. <br />APPLICANT: YA (-M l 091L4- t-1 C, ✓ BUSINESS/AGENCY: N <br />ADDRESS: -1-1 LA 4 A -T& (3L'f4CY) LJA 9 CITY/STATE/ZIP: rJ7-2 UPC—_ 1J Li 2 <br />PHONE (1): CA i 6 — Cl.`) p b� /� PHONE (2): FAX OR E-MAIL: �REA'►AmEA, 2 <br />R1toc b E4RNao <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 aen-y.,c. 'rwvi DATE "ugflee <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 infoRsicehd.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 />'� dr oa T �� -�" F/ <br />4. Any file not returned in the same condition as released a reorganized y D staff at he expen a of the applicant —1 f'� <br />Future file reviews by the same applicant may require a $152 deposit prior to review. ,�/ o <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:OOPM (EXCLUDING HOLIDAYS) [[( <br />Electronic Information: ❑ List ❑ Map — Description: <br />Specific Date Range of Information Requested: From <br />to 2.. $ <br />ENVIRONMENTAL <br />FILE ADDRESS <br />HEALTH DEPARTMENT <br />(Specific addresses <br />onsy, address ran9es will <br />not be accepted) <br />EHD USE ONLY <br />Underground Tank (UST) <br />Street # <br />Street Name <br />City <br />Cleanup Site (LOP) <br />-1 10 0 <br />M 9, H Y fM.&jhL <br />LA Im RA <br />52 -'CONSUMER <br />Other Cleanup Site (Non -LO ) <br />49-\Llti% <br />EN Hazardous Waste <br />t 4�1i.�M� 1r1i�/ <br />AIRY <br />Sl Tiered Permitted Facility <br />2 <br />04S <br />Aboveground Tank <br />C <br />N"PWS <br />UST (Monitoring / Removal) <br />Hazardous Materials14 <br />s <br />`` <br />�5 <br />Spill / Release Response <br />4 <br />1 <br />WATER QUALITY <br />Solid Waste Facility / Vehicle <br />Food Facility <br />/4/tel <br />� ^ � <br />� <br />SITE MITIGATION <br />Pool /Spa <br />Dairy <br />� <br />Land Use Application Sites <br />Septic Pumper Truck / <br />e <br />�; , "� <br />yt <br />OUSING <br />Yard / Chemical Toilets <br />��y <br />Wastewater Treatment Plant <br />COPA <br />Housing Abatement <br />7 <br />AST / HM / HW <br />dMotel/Hotel <br />1 <br />CUPA <br />Chicken Ranch / Dog Kennel <br />Medical Waste Facility <br />8 <br />Tattoo/Body Piercing <br />LPUST <br />` SOLID WASTE <br />Waste Tire <br />9 <br />1\v <br />Complaint <br />Other (Please Specify): <br />El AMOUNTING <br />10 <br />'BOXED AREA - EHD USE ONLY '* <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />