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1��,�r t tj r p C f EHD LOG NUMBER SAN JOAQUIN COUNTY fd*74 � �� ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 -i one: (209)468-3420 Fax: (209)464-0138 Web:www,s'cehd.com Email: info(@sicehd.com IrtVI�tCNtJ�]�1A1 h4lPUBLIC RECORDS RELEASE APPLICATION PEt�MlT��f�ACES APPLICANT: p , �1� Gt, BUSINESS/AGENCY: ADDRESS: 7J CITYISTATE/ZIP: PHONE(1): C O - S f P ONE(2): FAX OR E-MAIL: Please allow 10 business days from date of application submittal for the records to be available. Staff will contact you to arrange an appointment date and time to review the requested records. ❑ CHECK BOX TO EXPEDITE REQUEST-$139 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OF APPLICANT DATE 1. List us)to ten addresses in the space below. Address ranges will not be accepted. Select the type(s) of files from the list below by checking the appropriate box(es). At least one file type MUST be selected. Fax to 209 464-0138 mail to the address indicated above or email to info@slcehd.com. Applications received after 3:00 pm will be processed the next business day. 2. For assistance in identifying the nature and content of EHD records, please contact EHD at the number noted above. 3. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a$139 deposit prior to review. WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) Electronic Information: ❑ List❑ Map-Description: Specific Date Range of Information Requested: From to ENVIRONMENTAL FILE ADDRESS HEALTH DEPARTMENT ( p 9 ) EHD USE ONLY FILES (Specific addresses only, address ranges will not be accepted ❑UNDERGROUND TANK(UST) Street# Street Name City CLEANUP SITE(LOP) I CONSUMER OTHER CLEANUP SITE(NON-LDP) yAGAn ❑HAZARDOUS WASTE ❑DAIRY ❑TIERED PERMITTED FACILITY 2 ❑ABOVEGROUND TANK ❑ PWS UST (MONITORING I REMOVAL) ❑ ❑HAZARDOUS MATERIALS 3 ❑SPfLLIRELEASE RESPONSE ❑WATER QNALLY ❑SOLID WASTE FACILITY I VEHICLE 4 ❑FOOD FACILITY ❑POCL I SPA ❑SITE MITIGATION ❑DAIRY 5 ❑LAND USE APPLICATION SITES ©Housuuc ❑SEPTIC PUMPERTRUCKI B YARD/CHEMICAL TOILETS ❑WASTEWATER TREATMENT PLANT ❑CUPA ❑HOUSING ABATEMENT 7 ❑MOTELIHOTEL ❑CHICKEN RANCH/DOG KENNEL ❑CUPA-UST 8 ❑MEDICAL WASTE FACILITY ❑TATTOOI9ODY PIERCING ❑SOLID WASTE ❑WASTE TIRE g COMPLAINT E?67HER(PLEASE SPECIFY): i]ACCOUNTING 10 ••soxEo AREA-r=HD USE ONLY•• 11 Records provided by Staff-PPR Complete. Staff Name;