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DATE RECEIVED SAN .JOAQUIN COUNTY EHD LOG NUMBER <br /> JUL O 7 20fa ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ENI'A ONMENTAP..i-VIM' phone: (209)468-3420 Fax: (209)464-0138 Web:www.sigov.org/ehd <br /> PERMIT/SER \flCES PUBLIC RECORDS RELEASE APPLICATION <br /> PLICANT: (NYIS(VAye-'Z� BUSINESS/AGENCY: <br /> ADDRESS: CITY/STATE/ZIP: <br /> PHONE (1): C—T— <br /> q- (a PHONE(2): FAX OR E-MAIL: <br /> Please allow 10 business days from date of application submittal far the records to be available. <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$130 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> 1. List up to ten addresses in the space below. Select the type(s) of files from the list below by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(269)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 $130 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM (EXCLUDING HOLIDAYS) <br /> EPectronic Information: ❑ List El Map– Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FELE ADDRESS EHE) USE ONLY <br /> FILES <br /> Rf UNDERGROUND TANK(UST) Street# Street Name City <br /> Y'-CLEANUP SITE(LOP) CONSUMER <br /> OTHER CLEANUPSITE(NON-LOP) 7 <br /> HAZARDOUS WASTE 01 <br /> ❑DAIRY <br /> TIERED PERMITTED FACILITY <br /> ABOVEGROUND TANK _ ___-___._____ .______ _.._-__--_—.—_. - <br /> PWS <br /> ip UST (MONITORING/REMOVAL) <br /> 3 <br /> HAZARDOUS MATERIALS <br /> SPILURELEASE RESPONSE WATER QUALITY <br /> ❑ <br /> SOLID WASTE FACILITY/VEHICLE 4 <br /> ❑FOOD FACILITY ?/1 <br /> SITE MITIGATION l✓ <br /> ❑ <br /> POOL/SPA <br /> ❑DAIRY 6 <br /> ❑LAND USE APPLICATION SITES [3 HCL'EING <br /> ❑SEPTIC PUMPERTRUGK/ 6 <br /> YARD/CHEMICAL TOILETS <br /> ❑WASTEWATER TREATMENT PIANT CUPA <br /> ❑HOUSING ABATEMENT Z <br /> ❑MOTEL/HOTEL CUPA-HAZ-MAT <br /> E]CHICKEN RANCH/DOG KENNEL <br /> 6 <br /> MEDICAL WASTE FACILItt <br /> ❑TATTOO/BODY PIERCING ❑SOLID WASTE <br /> WASTETIRE 9 <br /> ❑COMPLAINT <br /> ❑OTHER(PLEASE SPECIFY): AccOUNTING <br /> 70 <br /> "'BOXED AREA-EHD USE ONLY— <br /> ❑ Records provided by Staff-PPR Complete. staff Name: <br /> EHD 4a-O6 <br />