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EHD LOG NUMBER <br />DA C� V SAN JOAQUIN COUNTY <br />�. �0 11RONMENTAL HEALTH DEPARTMENT <br />1868 ast Hazelton Avenue, Stockton, CA 95205-6232 r * <br />U11 2 0 2M %� Olephcne: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />u '"4 PUBLIC RECORDS RELEASE APPLICATION <br />PPu $P�Sf9ET4 7G�e:pj fs fY1urK �Pl vjdat� BUSINESS/AGENCY: (AS Cwt a�hio <br />ADDRESS: IaqZo ldesfs�r 21 , - pr', Sr' fro CITY/STATE2EP:6794-�aM-f"DWIIMp 2;-7& <br />PHONE (1): ', (-Q270--42:mf PHONE (2):(aOij)-j7� 7- TtO FAXORE-MAIL: C 1 g2C�" Jam( <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 />❑ 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 uD 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 (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 Hies 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-5:00PM (EXCLUDING HOLIDAYS) <br />Electronic Information: ❑ List ❑ Malo — <br />Range of Information Requested: From <br />to 201 b <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />PILE ADDRESS <br />EHD USE ONLY <br />FILES <br />UNDERGROUND TANK (UST) <br />Street <br />Street Name <br />City <br />Z' 22 <br />��� <br />5 S is1 Y Y vPi <br />S jo an <br />/e. /�f CONSUMER <br />'I c,/2f, A2) J �I <br />CLEANUP SITE (LOP) <br />OTHER CLEANUP (LOP) <br />( NON- <br />UAID <br />L•J .,.-.....wo ..na r c <br />TIERED PERMITTED FACILITY <br />ABOVEGROUND TANK <br />BUST (MONITORING / REMOVAL) <br />dHAZARDOUS MATERIALS <br />19,SPILVRELEASE RESPONSE <br />SOLID WASTE FACILITY / VEHICLE <br />❑ FOOD FACILITY <br />❑ POOL/ SPA <br />❑ DAIRY <br />❑ LAND USE APPLICATION SITES <br />❑ SEPTIC PUMPER TRUCK/ <br />ZARO / CHEMICAL TOILETS <br />V WASTEWATERTREATMENTPLANT <br />❑ HOUSING ABATEMENT <br />❑ MOTEL/HOTEL <br />❑ CHICKEN RANCH / DOG KENNEL <br />❑ MEDICAL WASTE FACILITY <br />❑ TATTOO/BODY PIERCING <br />Fg�WASTE TIRE <br />❑ COMPLAINT <br />❑ OTHER(PLEASE SPECIFY): <br />z I I I II ❑ DAIRY <br />Ej PWS <br />6 I I I I E5SBE MITIGATON <br />6 I I ❑ HOUSING <br />7 1 1 1 <br />8 I I I J;fCUPA -HAZ-MAT <br />9 I I I g SOLID WASTE <br />D I I I lI [D ACCOUNTING <br />-BOXED AREA - EHD USE ONLY**' <br />✓l I r n /. <br />i <br />❑ Records provided by Staff -PPR Complete. staff Name: .. <br />EHD 48-06 <br />