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Frohn: Erik Brown Fax:(888)828-2635 rc x.; (209)464-0138 Page 2 of 2 12/2812017 10:52 AM <br /> �)I lV D <br /> -x:W:`ti-•` Rif <br /> ,� .(z' itaIj Cy il' t�'iu i a <br /> .w &. if x.y. } F Rf tt, <br /> ..f � . r DECrklr@.NIi ?ifGN� 1 -ui ?ia n•lp I �€ 1. Ry <br /> r�,6....... (�1 / UB��c Eco�,Ds RELEASE APPLICATION <br /> -..MAVI&F.WA1 WALy1�Z_y <br /> EHD L.®V N1...1IVIBEER: <br /> APPLICANT: <br /> ADDRESS: 4USINESSIAGENCY: y�L <br /> e-PI <br /> . <br /> 5 ;tll _ CITYISTATEIZIP: j <br /> PHONE(1): PHONE(2): FAX OR E-MAIL: <br /> 'c`r � Cp t+ Ytr - : COQ, <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact:you to arrangpn�Ipoint it.date.and time to review the requested records. <br /> SIGNATURE OF APPLICANT ��� =� PATE <br /> 1. List el to ton addresses in thr,space f�eaa ddre s� "es WILL NOT be accepted. Select the type(s)of files from the <br /> list below by checking the appropriate box(es). At least one file type MUST be selected. Fax to 1203)464-0135 mail to the <br /> address indicated below,or email to infoosicehd corn Applications received after 3:00 Pm Will be processed the neaxf <br /> business day, <br /> 2. For assistance in identifying the nature and content of EHD records, please contact EHD at the number noted be-low. <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. /u <br /> Future fele reviews by the same applicant may require a$152 deposit prier to review. �J C1lI t� <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: 1d ONDAY-FRJDAY 8:00 AM-5:00PMt(EXCLUDING HOLIDAYS) <br /> Electronic Ireformation: ❑ List❑ Map—.Description: <br /> Specific Bate Range of information Requested: From to <br /> ENVIRONMENTAL FILE ADDRESS <br /> HEALTH DEPARTMENT <br /> FILES (Specific addresses only,address ranges will not be accepted) EHDUSE ONLY <br /> Underground Tank(UST) Street# <br /> i Street Name _�— city <br /> Cleanup Site(LOP) <br /> ❑CONSUMER <br /> it Other Cleanup Site(Nan-LOP) t f`� 1 <br /> 'Hazardous Waste <br /> Tiered Pnrmifted Facility 2 <br /> i 11 DAIRY •i1�p•I <br /> MIAboveground Tank <br /> j UST (Monitoring/Removal) j <br /> y J-lazardous Materials <br /> 3 ❑PWS <br /> Spill/Release Response <br /> F]Solid Waste Facility/Vehicle 4 ATER QLIAy nY <br /> Food Facility <br /> I <br /> [l Pool/Spa - _ <br /> Dairy 5 SrTcMmc�fnTbN <br /> Land Use Application sites - Iva I_•- HI-1 X <br /> 171 Septic Pumper Truck/ ❑NOusi,G <br /> 6 <br /> Yard/Chemical Toilets <br /> Wastewater Treatment Plant <br /> Housing Abatement 7 CUPA <br /> Motel/Hotel <br /> n.ST I HM I HW <br /> ,l <br /> [�Chicken Ranch/Dog Kennel <br /> g <br /> Medical Waste Facility CUPA <br /> Tattoo/Body Piercing UST <br /> i <br /> F]Waste Tire 8 ©SOUD WAs•re <br /> I I]Complaint f <br /> other(Please Specify): <br /> — 'tO � �ACCOUNTING <br /> EhiD DSE QNLr" .. <br /> I,. � iC. tnR. �nctiV�L.•C.l[r` �Fel <br /> --'❑ Rece3rds provided b Staff-PPI3 ComplBte. StafrName: <br /> 6HD®g-06 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 f T 209 468-3,420 1 F 209 464-0138 1 Vnr,tw.sjcehd.coM <br /> `Received Ti -ne Dec, 28, 2017 10:46AM No, 2795 <br />