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SANIJOAQUIN RECEI onmentao Heafth Department <br />—COU N TY --SEB O $_ 201 PU� LIC RECORDS RELEASE APPLICATION <br />600(—L Greatness yron0> here�l{kEHDLOG NUMBER: <br />•APPLICANT: AR MI ijV& - S' > I G BUSINESS/AGENCY: 3i;)t N R_&AL-r y <br />ADDRESS: -1-1 LAI 1-1,� F}7G (3kt4e-v1 W A 9 CITY/STATE/ZIP: A L_� <br />PHONE (1): CA ( 4 —"l o — g') t l PHONE (2): FAX OR E-MAIL:6&ATPAmLcR1cA 2oo4 E4RNao <br />Please allow 10 business days from date of application submittal for the records to be available. Co h,, <br />Staff will contag you to arrange an appointment date and time to review the requested records. <br />SIGNATURE OF APPLICANTDATE ')� <br />1. List un 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 info(alsicehd.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. _,[,r/ <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 8:00 AM-5:00PM (EXCLUDING HOLIDAYS) <br />Electronic Information: Lj List U Map — Description: I <br />Specific Date Range of Information Requested: From to 2-19 1 1 K <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FILES <br />(Specific addresses <br />FILE ADDRESS <br />only, address ranges will not <br />be accepted) <br />EHD USE ONLY <br />Underground Tank (UST) <br />Street # <br />Street Name <br />City <br />Cleanup Site (LOP) <br />Other Cleanup Site (Non -LO <br />I'1 �� <br />ryt U O ?H y <br />1 • 1rV F <br />LA 7n R,p <br />oNSUMER <br />Hazardous Waste <br />Tiered Permitted Facility <br />2 <br />ASIIe�A P)I-tMl01 <br />AIRY <br />Aboveground Tank <br />�//� P <br />PWS <br />UST (Monitoring / Removal) <br />Hazardous Matedals <br />r, <br />Spill l Release Response <br />S <br />/%/ O <br />r <br />r <br />4 <br />WgTaR qugtm <br />Solid Waste Facility / Vehicle <br />Food Facility <br />/� <br />SnE MITGgTON <br />Dairy Pool/ Spa <br />Dairy <br />Land Use Application Sites <br />Septic Pumper Truck / <br />> <br />CI-- <br />Guslxo <br />6 <br />5�y� I ViLO <br />Yard / Chemical Toilets <br />�-t Wastewater Treatment Plant <br />CU' <br />,4! <br />Housing Abatement <br />y <br />AST/HM/HW <br />Motel/Hotel <br />8 <br />UPA <br />UST <br />® Chicken Ranch / Dag Kennel <br />(� Medical Waste Facility <br />Tattoo/Body Piercing <br />aouo WgsiE <br />Waste Tire <br />g <br />Complaint <br />Other (Please Specify): <br />to <br />AccouNnxc <br />***BOXED AREA - EHD USE ONLY*** <br />Ad Kc Cii Get V <br />❑ Records provided by Staff -PPR Complete. staff Name: — EHD 49-66 <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />