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RECRAPAQUIN Environmental Health Department, <br /> /SPR &-2--206U NTY-- PUBLIC RECORDS RELEASE APPLICATION <br /> ENUiRONMENTAL HEALT4 e1 F (JaN up <br /> p EHD LOG NUMBER: <br /> •APPLICANT: BUSINESS/AGENCY:UyrJN N�6Sr acs$ <br /> ADDRESS: O '60%4 -1 S 0`41 CITY/STATE/ZIP: SF Lk ('JJ <br /> PHONE (1�) Ck Z p ;- PHONE (2): FAX OR E-MAIL:::,Jm,;e <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact y o ar a ge an appointment date and time to review the requested r cords. <br /> SIGNATURE OF APPLICANT DATE g <br /> 1. List up to ten addresses in the space below. Address ranges WILL NOT be accepted. Select the type(s) 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(d)slcehd.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) 10 <br /> Electronic Information: ❑ List❑ Map—Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL FILE ADDRESS <br /> HEALTH DEPARTMENT Only, 9 accepted) EHD USE ONLY <br /> FILES (Specific addresses address ranges will not be acce ted <br /> ❑Underground Tank(UST) Street# Street Name city <br /> Cleanup Site(LOP) C ❑CONSUMER <br /> Other Cleanup Site(Non-LOP) t \UI S O � ` S,r�G, <br /> ❑ Hazardous Waste ST gD RY <br /> ❑Tared Permitted Facility <br /> 'Aboveground Tank 1 <br /> ❑ UST (Monitoring/Removal) /) AL <br /> Hazardous Materials <br /> ❑ Spill/Release Response 'n <br /> ❑ Solid Waste Facility/Vehicle 4 I P (IbWAWATER QUALITY <br /> ❑Food Facility S/11L/r <br /> ❑ Pool/Spa ❑SITE MITIGATION <br /> Dairy 5 <br /> P1 Land Use Application Sites <br /> E] Septic Pumper Truck/ 8 ❑HOUSING <br /> Yard/Chemical Toilets <br /> ❑Wastewater Treatment Plant VUPA <br /> ❑ Housing Abatement r AST/HM/HW <br /> ❑Motel/Hotel <br /> ❑Chicken Ranch/Dag Kennel ❑CUPA <br /> 8 UST <br /> ❑Medical Waste Facility <br /> ❑Tattoo/Body Piercing 0 SOLID WASTE <br /> ❑Waste Tire g <br /> ❑ Complaint <br /> d%)Other(Please Specify): ❑Accouxnxc <br /> �° <br /> ***BOXED AREA-EHD USE ONLY*** <br /> ❑ Records provided by Staff-PPR Complete. start Name: eHQ ae-5s <br /> 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />