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''RECE vi ro,Ill rule,nta� Heal"i"'h r0apar'-B-fienit <br /> i �0R fit-% j&UNTY - AI, PUBLIC RECORDS RELEASE APPLICATION <br /> AVfROf�MENTA�FiEALTFI <br /> p EHD LOG NUMBER: <br /> APPLICANT: I3USINESSIAGENCY:bj r40 Sri u�—v r,\C--rTS <br /> ADDRESS: yu '-' CITYISTATEfZIP: `�-�U uzf " <br /> PHONE (10.0`\ •��`,,�,,3 S" PHONE (2): FAX OR E-MAIL::Z'Sm4c <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact y oar e an appointment date and time to review the requested r cords. <br /> SIGNATURE OF APPLICANT _ �-- DATE `-[ IaA Ig <br /> 1. List up to ten addresses in the space below. Address ranges WILL NOT be accepted. Select the types) of files from the <br /> list below by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209)464-0138, mail to the <br /> address indicated below, or email to infoftsicehd.com. Applications received after 3:00 pm will be processed the next <br /> business day. <br /> 2. For assistance in identifying the nature and content of EHD records, please contact EHD at the number noted below. <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 $152 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 ❑ Map— Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL FILE ADDRESS <br /> HEALTH DEPARTMENT ( Aonly, g a ) EHD USE ONLY <br /> FI LES <br /> (Specific addresses address ranges wil t be accepted) <br /> Underground Tank(UST) Street# Street Name city <br /> Cleanup Site(LOP) <br /> CONSUMER <br /> Q <br /> Other Cleanup site(Non-LOP) <br /> �v l� L ��� ❑ <br /> I1 Hazardous Waste 5l KDAIRY <br /> ❑Tiered Permitted Facility <br /> 'Aboveground Tank 1 <br /> D� r7lj lJe ws <br /> LIST (Monitoring/Removal) <br /> 3 Co P'V7 <br /> Hazardous Materials ��� l.�ov 7 <br /> Spill/Release Response lam' <br /> WATER QUALITY <br /> Solid Wasto Facility/Vehicle 4 r <br /> ❑ Food Facility <br /> ❑ Pool!Spa ❑SITE MrnwioN <br /> Dairy f <br /> N Land Use Application Sites ' <br /> *� ❑HousiNc <br /> Septic Pumper Truck 1 e <br /> Yard I Chemical Toilets <br /> ❑Wastewater Treatment Plant UPA <br /> Housing Abatement 7 1 AST/HMIHW <br /> motel/Hotel + <br /> ❑Chicken Ranch!Dog Kennel ❑C1JPA <br /> a qqu-� <br /> UST <br /> Medical Wasie FacilityAr <br /> ❑Tattoo/Body Piercing p SOLID WASTE <br /> H Waste Tire g <br /> Q Complaint <br /> Other(Please S1p�e(clffyy): ❑AccouNTINs <br /> 10 <br /> ***BOXED AREA-EHD USE ONLY— <br /> ❑ Records provided by Staff-PPR Complete. stair Name: EHD 48-06 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 2C9 468-34201 IF 209 464-0138 1 www.sjcehd.com <br />