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SAN JOAQUIN RECEIV6Pim.mental Health Department <br /> ---COUNTY OCT O 2O9] PUBLIC RECORDS RELEASE APPLICATION <br /> Greatness grows (tete NAV V41 <br /> 3p" J <br /> ENVIRONMENTAL2FRIAIHE1e EHD LOG NUMBER <br /> aGar�ITISEI�Pr^sea <br /> •APPLICANT: n ir i cALCL t ( a S BUSINESS/AGENCY: <br /> ADDRESS: _� ZG t , 8+ S CITY/STATE/ZIP: !S+oc K+6 K) Y(A � 0/5 Z O6 <br /> PHONE (1): $rjnrj PHONE (2): FAX OR E-MAIL: rfcy car Jun�rsmelyn qrl r <br /> Please allow 10 business days from date of application submittal for the records to be available. �T <br /> Staff will contact you to ar nge an appointment date and time to review the requested records. <br /> SIGNATURE OF APPLICANT S DATE��/1. List up to ten addresses in the space below. Address ranges WILL NOT be accepted. Select the t pe(s) o files f�f tom 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(cDsicehd.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:OOPM(EXCLUDING HOLIDAYS) 11/7 <br /> Electronic Information: ❑ List❑ Map— Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL FILE ADDRESS <br /> HEALTH DEPARTMENT ( p y 9 p ) EHD USE ONLY <br /> FILES (Specific addresses onlyaddress ran es will not be acre ted <br /> Underground Tank(UST) Street# Street Name City <br /> Cleanup Site(LOP) ❑CONSUMER <br /> Other Cleanup Site(Non-LOP) <br /> r201 5 • cen + � r s+ocK�ot <br /> Hazardous Waste p DAIRY <br /> tiered Permitted Facility i <br /> N�Aboveground Tank <br /> M'UST (Monitoring/Removal) PWS <br /> a <br /> Hazardous Materials <br /> Hs <br /> KSSpill/Release Response <br /> 11 Iq 1t1 11 QUALRY <br /> Solid Waste Facility/Vehicle 4 <br /> Food Facility <br /> Pool/Spa latrrE MnIGAToN <br /> El Dalry 5 <br /> ❑Land Use Application Sites <br /> OOSING <br /> ❑ Septic Pumper Truck/ a F. <br /> Yard/Chemical Toilets <br /> Wastewater Treatment Plant Q,6PA <br /> H using Abatement 7 _ AST/HM/HW <br /> Motel/Hotel <br /> Chicken Ranch/Dog Kennel UPA <br /> B UST <br /> Medical Waste Facility <br /> ❑Tattoo/Body Piercing ouo WASTE <br /> Waste Tire g <br /> Complaint <br /> ❑Other(Please Specify): ❑Accou"NG <br /> in <br /> `.BOXED AREA-EHD USE ONLY— <br /> ❑ Records provided by Staff-PPR Complete. staff Name: EHD 4S06 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />