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DAT 'CEI VE® SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> f tt3 14 2011 ENVIRONMENTAL HEALTH DEPARTMENT 015(91 <br /> 1: (2 East Hazelton Avenue, Stockton, CA b:ww .sig Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> I�IYiRONAd£PiL�LfikiTH PUBLIC RECORDS RELEASE APPLICATION <br /> OCLUNME TA M`MA <br /> •APPLICANT: hct(y XyiiY d16 BUSINESS/AGENCY: TIz , oI IFIOns <br /> ADDRESS: �p �2jolaflt bIud Etp �d7 CITY/STATE/ZIP:_ HTIQlUjU1 WT l6111 <br /> PHONE(1): (B0 j 1 a(b—JqI(I PHONE (2): (000 qZ FAX OR E-MAIL: K9Wjn6jjf.R)'fYfif0jo Clf�lb. <br /> Please allow 10 business days from date of application submittal for the records to be available. WIT) <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$139 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 be 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 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$139 deposit prior to review. <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM (EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List ❑ Map—Description: <br /> Specific Date Range of Information Requested: From to _ <br /> ENVIRONMENTAL <br /> HEALTH DEPARTME FILE ADDRESS <br /> FILES EHD USE ONLY <br /> UNDERGROUND TANK(UST) f—Street# Street Name City - <br /> OTHANUP SI CLEANUP <br /> SITE <br /> �2p S Gh�vkee Ln IA CONSNME- <br /> OTHER CLEANUP$ITE(NON-L <br /> ' Lodi <br /> R1 HAZARDOUS WASTE <br /> DAIRY <br /> CJI TIERED PERMITTED FACILITY 2 <br /> ABOVEGROUND TANK <br /> UST (MONITORING/REMOVAL) I]PWS <br /> HAZARDOUS MATERIALS B <br /> N7 SPILURELEASE RESPONSE WATER QUAD <br /> TY <br /> SOLID WASTE FACILITY/VEHICLE 4 <br /> FOOD FACILITY <br /> In POOL/SPA $ITE MITIGATION <br /> l[DAIRY 6 <br /> LAND USE APPUCATION SITES <br /> SEPTIC PUMPER TRUCK/ HOUSING <br /> B <br /> YARD/CHEMICAL TOILETS <br /> WASTEWATER TREATMENT PLANT C41PA <br /> 9HOUSINGASATEMENT 7 <br /> Ix MoT L/HoTEL <br /> 91 CHICKEN RANCH/DOG KENNEL <br /> CUPA-UST <br /> 8 <br /> MEDICAL WASTE FACIDTY <br /> V TATTOO/BODY PIERCING <br /> WASTE TIRE Souo WASTE <br /> 9 <br /> „COMPLAINT <br /> IC,OTHER(PLEASE SPECIFY): 13 ACCouNTING <br /> tF <br /> "'BOXED AREA-EHD USE ONLY" records provided by Staff-PPR Complete. staff Namur <br /> EHD 48-06 <br />