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EHD LOG NUMBER <br />D !f DECEIVED SAN JOAQUIN COUNTY <br />6 APR d �VIRONMENTAL HEALTH DEPARTMEN <br />2��� Z� 1 68 East Hazelton Avenue, Stockton, CA 95205-6232 <br />14' Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sigov.org/ehd <br />ENVIRONMENTAL PUBLIC RECORDS RELEASE APPLICATION <br />)APPLICANT: BUSINESS/AGENCY: <br />ADDRESS: CITY/STATE/ZIP: <br />PHONE (1): r9/� 7z7IF—Kg19 PHONE (2): FAX OR E-MAIL: <br />Please allow fO business days from date of application submittal for the records to be available. <br />Staff will contact YOV to arrange an appointment date and time to review the requested records. <br />❑ CHECK BOX TO EXP E T - $139 FEE (CASH OR CHECK ONLY) -REQUEST PROCESSED IN 3 B ES DAYS <br />SIGNATURE OFAPPLICA T DATE LY <br />1. List up to ten addresses in a ace below. Select the type(s) of files from the list below by checki g th appropriate <br />box(es). At least one file type UST 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. J <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY -FRIDAY 0:00 AM-5:OOPM (EXCLUDING HOLIDAYS) <br />Electronic Information: ❑ List ❑ Map — Descrii <br />Specific Date Range of Information Requested: From <br />to <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />FILE ADDRESS <br />v) U `7 1��P5• 5'IZ'I <br />'FILES <br />EHD USE ONLY <br />NDERGROUND TANK (UST) <br />Street # <br />Street Name <br />City <br />Uy/D /{J'� <br />/� p n /f <br />�(t�`V(OVAt' <br />Sj�(jC�,47OVJ <br />�J <br />CONSUMER <br />l <br />tF CLEANUP SUE (LOP) <br />/ THERCLEANUPSITE(NU0.OP <br />V1�(l <br />If I <br />�. <br />dHPZARDOUS WASTE <br />DAIRY <br />❑ TIE D PERMUTED FACILITY N, <br />BOEVEGROUNO TANK U <br />1 <br />(MONRORING/REMOVA ))If <br />/STT <br />�H'1AZARDOUS MATERIALS <br />3 <br />0PWS <br />PILURELEASE RESPONSE 1 <br />❑ SOLID WASTE FACILITY /VEHICLE <br />4 <br />WATER QUAUlY <br />�oOD FACT <br />❑ POW'/SPA <br />SITE ARIKv ION <br />❑ DAIRY <br />5 <br />❑ LAND USE APPLICATION SITES <br />B <br />❑ HOUSING <br />❑ SEPTIC PUMPER TRUCK/ <br />YARD / CHEMICAL TOILETS <br />❑ WASTEWATER TREATMENT PLANT <br />CUPA <br />❑ HOUSING ABATEMENT <br />7 <br />❑ MOTEL/HOTEL <br />CUPA- UST <br />❑ CHICKEN RANCH I DOG KENNEL <br />❑ MEDICAL WASTE FACILITY <br />B <br />❑ TATTOO/BoDY PIERCING <br />❑ WASTE TIRE <br />B <br />❑ SOLE) WASTE <br />�[�COMPLAINT <br />❑ACCOUNTING <br />THER(PLEASE SPECIFY): <br />Gr— "'BOXED AREA -EHD USE ONLY" <br />.. ..f ►.! _.G <br />■ Records provided by Staff -PPR Complete. <br />�nFe• <br />