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"EG <br /> EPAQUIN <br /> � a J <br /> AIR H--2 U NTY---- PUBLIC RECORDS RELEASE APPLICATION <br /> HL <br /> t�rar.!1. :�rGivS fl2r� r J� <br /> `E[�VIRONNfENTAL HEAI..TH <br /> p EHD LOG NUMBER: <br /> •APPLICANT: BUSINESSIAGENCY:_b•u!Jr' 1r1yfAi•t�,G-f7$ <br /> ADDRESS: CITYISTATEIZIP: S <br /> PHONE ( 3� �` �.�} � PHONE(2): FAX OR );-MAIL: v �Sy�1eQvaa , r.1� <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contacty a ar a an appointment date and time to review the requested r cords, <br /> SIGNATURE OF APPLICANT DATE `j k <br /> 1. List up to ten addresses in the space below. Address ranges WILL NOT be accepted. Select the types) of files from the <br /> list below by checking the appropriate box(es). At feast one file type MUST be selected. Fax to (209)464-0138,mail to the <br /> address indicated below, or email to infoPsicehd.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. f <br /> WELT.AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 5;00 AM-5:00PM(EXCLUDING HOLIDAYS)�[[C? <br /> Electronic Information: ❑ List ❑ Map -- Description: <br /> Specific Data Range of Information Requested: From to <br /> ENVIRONMENTAL FILE ADDRESS <br /> HEALTH DEPARTMENT ( p y, 9accepted) EHD USE � �¢ <br /> FILES S(Specific addresses onl address ran es will not be <br /> l]Underground Tank(UST) Street# Street Mame City <br /> Cleanup Site(LOP) ( ❑CONSUMER <br /> Other Cleanup Site(Non-LOP) 1� u �LL� S„�:`� <br /> 11 <br /> 1]Hazardous Waste y <br /> DAIRY <br /> Tiered Permitted Facility Z C <br /> ;?'Aboveground Tank 1 Cl <br /> ❑ UST (Monitoring)Removal) n 41lu 1 1b wS <br /> a f! 1 1 <br /> Hazardous Materials hit���� <br /> ❑Spill!Release Response �(] <br /> N�NATFR <br /> ❑Solid Waste Facility 1 Vehicle 4 <br /> Food Facility <br /> ❑ Pool 1 Spa Q SITE 01TIGA-WN <br /> Dairy 5 <br /> Land Use Application Sites <br /> ❑ HOUSING <br /> Septic Pumper Truck 1 ❑ <br /> 6 <br /> Yard 1 Chemical Toilets <br /> ❑ Wastewater Treatment plant UPa <br /> Housing Abatement 7 AST I HM 1 HW <br /> n Motel/Hotel <br /> F] Chicken Ranch I Dog Kennel ❑CUPA <br /> s UST <br /> ❑ Medical Waste Facility <br /> Tattoo/Body Piercing ❑SOLID WASTE <br /> Waste Tire 9 <br /> Complaint <br /> 1�Other(Flease Specify): <br /> ACCOUNTING <br /> ***BOXED AREA-EHD USE ONLY*** <br /> ❑ Records provided by Staff-PPR Complete. staff Name: EHD48-OE <br /> 1868 F. Hazelton Avenue I Stockton, Ca€ifornia 95205 J T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br />