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RECWD ED <br />SAN aIOAQUIN COUNTY RUSH EHD LOG NUMBER <br />NOV 2 1 2016 ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 8570 <br />�dTH Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />c,fES PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: 11, & BUSINESS/AGENCY: 661e <br />ADDRESS: T 77K Y1i?v1 (��,,, CITY/STATE/ZIP: ., N C -1 <br />PHONE (1): 15�)-y/Y-&C, X: PHONE (2): 5-X—7Y3--7V 9 3 FAX OR E-MAIL: J4 AV, 2-1 <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 />ECK BOX TO EXPEDITE RE QU 139 F (CASHGR ECK ONLY) - REQUEST PROCESSED IN 3 BUSINE S DAYS <br />SIGN TURE OF APPLICANT _ DATE / LS/ <br />1. List up to ten addresses in the space below. Select the type(s) of files from the list below by checking the dppropriate <br />box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address indicated above. Address <br />ranges will not be accepted. Applications received after 3:00 pm will be processed the next business day. <br />2. For assistance in identifying the nature and content of EHD records, please contact EHD at the number noted above. <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 $139 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 ❑ Map — Description: <br />Specific Date Range of Information Requested: From to <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FILE ADDRESS <br />EHD USE ONLY <br />FILES <br />UNDERGROUND TANK (UST) <br />Street # <br />Street Name <br />City <br />CLEANUP SITE (LOP) <br />,�( <br />I OTHER CLEANUP SITE (NON -LOP) <br />❑ CONSUMER <br />AZAROOUS WASTE <br />TIERED <br />) <br />DAIRY <br />PERMITTED FACILITY <br />�p TANK" <br />19 j <br />f'4111 <br />Ql.� <br />'` <br />7y�ABOVEGROUND <br />tet'.n <br />. <br />2�2 <br />PWS <br />UST (MONITORING /REMOVAL) <br />MATERIALS <br />IHAZARDOUS <br />SPILLJRELEABE RESPONSE <br />4 <br />WATER QUALITY <br />SOLID WASTE FACILITY /VEHICLE <br />FOOD FACILITY <br />f -I POOL / SPA <br />(SITE MITIGATION <br />E] DAIRY <br />n <br />LAND USE APPLICATION SITES <br />E] HOUSING <br />SEPTIC PUMPER TRUCK I <br />YARD / CHEMICAL TOILETS <br />6 <br />WASTEWATER TREATMENT PLANT <br />CUPA <br />HOUSING ABATEMENT <br />7 <br />MOTELIHOTEL <br />i <br />NICUPA - UST <br />CHICKEN RANCH I DOG KENNEL <br />MEDICAL WASTE FACILITY <br />8 <br />TATTOO/BODY PIERCING <br />SOLID WASTE <br />Ij WASTE TIRE <br />E] COMPLAINT <br />9 <br />OTHER(PLEASE SPECIFY): <br />ACCOUNTING <br />10 <br />"'BOXED AREA - EHD USE ONLY*** <br />77 00L7T22 n \,1ST - l v <br />C 0 o up I � <br />0 Records provided by Staff -PPR Complete. Staff Name: <br />EHD 48-06 f <br />II f 23 <br />17Ll <br />900(l <br />