Laserfiche WebLink
RECEIVED <br /> SAN 10AQUIN MAY 07 2,,, Environmental Health Department <br /> COUNTY r �h L PLIPBLIF <br /> RECORDS RELEASE APPLICATION <br /> EHD LOG NUMBER: <br /> APPLICANT: ✓i BUSINESS/AGENCY: e . <br /> ADDRESS: CITY/STATE/ZIP: r [/ <br /> PHONE(1): - PHONE(2): 4�- y�I� FAX OR E-MAIL: a , <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact yo1ro arrang n pointment date and time to review the requested ecords. <br /> SIGNATURE OF APPLICANT-_ DATE ��1419 <br /> 1. List up to ten addresses in t tt a space belo ddress 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 infoCdsicehd 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. j r <br /> Future file reviews by the same applicant may require a$152 deposit prior to review. 4J l0 <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 ADDRESS d U`7 i <br /> HEALTH DEPARTMENT FILE A <br /> FILES (Specific addresses only,address ranges will not be accepted) EHD USE ONLY <br /> nderground Tank(UST) street# Street Name City ❑ <br /> 10eanup Site(LOP) JJ � yr^. CONSUMER <br /> er Cleanup Site(Non-LOP) ' ��3 tN�S I LdGw 0 4 y CD t�P <br /> ardous Waste / <br /> N'T <br /> dPermittedFacili s r'J SJ / _ a r<)0 asr <br /> vegroundTankty aI� WWII A/r{- No iloe <br /> (Monitoring I Removal) I,/ �•' AJ0 u'2-T <br /> ardous Materials ' d3�T Wn1 �(LQ GtG Ai fl 9r1�� <br /> pili/Release Response <br /> Solid Waste + l�uo In Q n 1 �8 WATER um <br /> ❑ <br /> ❑Food Facility { I Op+Spa s )I, n <br /> ❑Dairy � vesr I �I ,M,uSZ SI is ��t - ©2312 slreMmcnlroN (V <br /> u{ 1 /��y <br /> ❑Land Use Application Sties ` H,+- Heusms 11 <br /> Septic Pumper Truck/ a d3 t� aj �y6 U91r� y t�Y <br /> ❑Yard I Chemical Toilets fi <br /> ❑Wastewater Treatment Plant r _ ri'Mw L / uo O 'e2j CUPA <br /> ❑Housing Abatement D (� (/j, !� '{ 4r 1 N O fl n ASTI HM I HW <br /> ❑Motel/Hotel ,J t N// %i CUPA <br /> ❑Chicken Ranch I Dog Kennel a UST <br /> ❑Medical Waste Facility <br /> ❑Tattoo/Body Piercing s ❑SOUDWpsre <br /> ❑Waste Tire <br /> ❑Complaint <br /> Other(Please Specify): 10 <br /> ❑Accouunxc <br /> `"'BOXED AREA-EHD USE ONLY" <br /> da ' - =rwi /tGzLA P rr c t , u kli r• +� <br /> • <br /> ❑ Records provided by Staff-PPR Complete.Stam Name: I Bu)4846 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />