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RECEIVED <br />SAN J OAQ U 1 ROY Z15 2016 Environmental Health Department <br />C= 0 L) N .t PUBLIC RECORDS RELEASE APPLICATION <br />PER ` !T BY EMAIL • Z!q q nn �l �H1 LAG NUMBER. <br />• <br />APPLICANT: BUSINESS/AGENCY: 'TL1'z-A-t,0A <br />ADDRESS: 102-1 E N A� c l i i�✓� I✓N `}{- GITY/STATE/ZIP: .G} c ik rt C& �Z° <br />PHONE (1): L911a}2ytn -St39� PHONE (2):_ FAX OR E-MAIL: F'il�ta-rt Dti" }ra-ra�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 an a ointment date and time to review theDATE ted records. <br />�s �8 <br />SIGNATURE OF APPLICANT — <br />1. List UP to #en addresses in the space below. Address ranges WILL NOT be accepted. Select the pe(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 infosicehd.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 END 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: <br />❑ <br />List Q Map <br />- Description: <br />From <br />t0 <br />Specific Date Range of Information <br />Requested: <br />NTAL <br />ENV7DEPARTMENT <br />FILE ADDRESS <br />2C� l� <br />Y <br />HEALT <br />( Specific addresses <br />only, address ranges will not <br />be accepted] <br />EHD USE O1 <br />Underground Tank (UST) <br />Street # <br />Street Name <br />City <br />CONSUMER <br />D 2 <br />r Cleanup Site (LOP) <br />�• rT WI <br />V'I Y <br />ISI other Cleanup Site (Non -LOP) <br />I l'� <br />� <br />❑ Dakv <br />Hazardous Waste <br />F-1TieredPermitted Facility <br />2 <br />� b q 9 <br />JJ <br />t; - S Ca+iT Avtn VJ <br />V t' v � <br />R Aboveground Tank <br />Sal,Nrt, ti5T <br />13 Pws <br />UST (Monitoring I Removal) <br />C)3S <br />e. St'ts A,rt-✓tie <br />.�1�L"-cry <br />y� <br />' `____ <br />Hazardous Materials <br />1 Release Response <br />u �Z t dt° <br />1 <br />WATER IUALITY <br />q <br />7 0 <br />7 D <br />Spill <br />&Solid Waste Facility / vehicle <br />( �i t� Q �LQ <br />J <br />D LkA-B <br />SAID � <br />N •�• <br />IJ Food Facility <br />„�,r� <br />Srri: MmcnrroN <br />[] Pool I Spa <br />Dairy <br />5 <br />�(1Q <br />drr <br />/N <br />�i. �1�01r� '�t:Rti' <br />c� cNv[.%�ii <br />• • <br />� f f <br />Ej <br />Land Use Application Sites <br />HOUSING <br />IJ Septic Pumper Truck! <br />J <br />r r'f nU� fa <br />J <br />4rg,7.-P_A <br />Yard I Chemical Toilets <br />Wastewater Treatment Plant <br />AST 1 HM / HW <br />t� Housing Abatement <br />T <br />F ­j Motel/Hotel <br />CUPA <br />Chicken Ranch I Dog Kennel <br />8 <br />UST <br />Medical Waste Facility <br />OLID WASTE <br />Tattoo/Body Piercing <br />Waste Tire <br />9 <br />Complaint <br />ACCOUNTING <br />other (Please Specify): <br />10 <br />_can ncP <br />r)Nt Y"' <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />