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RECEIVED <br /> SANJQ Q 1;14' 7j Environmental Health Department <br /> COUNTY PUB'IC RECORDS RELEASE APPLICATION <br /> �i{+0\ <br /> t (TT IL EHD LOG NUMBER: (3912.3 <br /> APPLICANT: !�� BUSINESS/AGENCY: o io <br /> ADDRESS: CITY/STATE/ZIP: (/ <br /> PHONE(1): - PHONE(2): FAX OR E-MAIL: a , <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to arran a an a pointment date and time to review the requestedecords. <br /> SIGNATURE OF APPLICANT_ �i. _ DATE 57/?I1 S <br /> 1. List up to ten addresses int a space belo ddress 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 END 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) l <br /> Electronic Information: ❑ List ❑ Map—Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL FILE ADDRESS 1 u HEALTH DEPARTMENT DEPARTMENT <br /> FILES (Specific addresses only,address ranges will not be accepted) EHD USE ONLY <br /> TUnderground Tank(UST) Street# Street Name City AD <br /> Cleanup Site(LOP) l a �,t ��j?, tow . 14A46 CONSUMER <br /> er Cleanup Site(Non-LOP) � 3 wi'S�" ttw li.vt, 0/.Sp <br /> azardous Waste ,/J / Nfl DAIRY <br /> I ed Permitted Facility s C /�r �"�" (�J C-0 <br /> oveground Tank i � N�_e I' <br /> e n <br /> JST(Monitoring I Removal) 3 ( I'kv + G 144n, i'vW, tol'71, PWS <br /> ardous Materials a3f'T WA's [exe <br /> pill I Release Response j 13-ddb WATER QUALITY <br /> ❑Solid Waste Facility I Vehicle 4 1 �� 11) �I S } <br /> ❑Food Facility ' t�' NoCo <br /> ❑Pool 1 Spa H nn SITE MITIGATION <br /> ❑Dairy W�S�ut ��U`' ✓1 f�0 CO 5 <br /> ❑Land Use Application Sites r)W, 4 AA LJ HousING <br /> Septic Pumper Truck( 6 <br /> Ei Yard 1 Chemical Toilets r `''`''/ �/"`^G' flv co ISO <br /> ❑Wastewater Treatment Plant a;_; ei m H M CUPA <br /> ❑Housing Abatement /0j(� `� �� � I t 4 JU, `'T LQ�S�ST I HM 1 HW <br /> ❑Motel/Hotel I CUPA <br /> ❑Chicken Ranch 1 Dog Kennel 6 UST <br /> ❑Medical Waste Facility <br /> Tattoo/Body Piercing 9 ❑SOLID WASTE <br /> ❑Waste Tire <br /> ❑Complaint i ❑ACCOUNTING <br /> Other(Please Specify): 10 i <br /> BOXED AREA-EHD USE ONLY— <br /> • : C,0 OO 3 t J- 0109190--vi <br /> �l t 5/06 <br /> f Co <br /> to#f-PP-R-Complete,-staff-Name: (p (Z Q � e f -] C� D <br /> w Ict'-t V L0004'2113. rPV t n ttvj -R I P 5325 71 S r•/� <br /> 1868 E. Hazelton Avenue j Stockton, California 95205 1 T 209 46-3,VO I F 209 464-0138 ( www.sjcehd.com <br /> Prov a sled tom w <br />