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RECEIVED lieSAN JOAQ I Environmental Health Department <br /> C O U N T Y-- AUG I t) 20V PUBLIC RECORDS RELEASE APPLICATION <br /> ���� Greatness c here.f 11/IR���-4 <br /> PENWiT)SEWtES EHD LOG NUMBER: <br /> APPLICANT: �M <br /> ADDRESS: �tX BUSINESSIAGENCY: '5J�i <br /> ���- I�t??.�JeN ��' � CITY/STATE/ZIP: _5 cp � <br /> ycy,, �5 �2 <br /> PHONE(1): 1 Z O� PHONE (2): FAX OR E-MAIL::be available. <br /> P ease allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> SIGNATURE OF APPLICANT DATE <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 infoP-sicehd.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) <br /> Electronic Information: ❑ List❑ Map—Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL FILE ADDRESS <br /> HEALTH DEPARTMENTEHD USE ONLY <br /> FILES (Specific addresses only,address ranges will not be accepted) <br /> ❑ Underground Tank(UST) Street# Streets�Naam/.e�y�� Ciit/ty]� <br /> ❑CONSUMER <br /> Cleanup Site(LOP) I <br /> 'nvJ <br /> Other Cleanup Site(Non-LOP) <br /> F­] 1 Hazardous Waste ❑DAIRY <br /> Tiered Permitted Facility 2 <br /> Aboveground TankEl PWS <br /> ❑UST (Monitoring/Removal) <br /> 3 <br /> Hazardous Materials <br /> R Spill/Release Response WATER QUALITY <br /> F]Solid Waste Facility/Vehicle q I r r <br /> ❑Food Facility t <br /> E]SITE MITIGATION <br /> ❑ Pool/Spa UU <br /> 5 <br /> ❑Dairy <br /> F] Land Use Application Sites HOUSING <br /> Septic Pumper Truck/ 6 <br /> Yard/Chemical Toilets <br /> CUPA <br /> Wastewater Treatment Plant <br /> AST/HM/HW <br /> Housing Abatement 7 <br /> EJ Motel/Hotel ❑CUPA <br /> El Chicken Ranch/Dog Kennel UST <br /> S <br /> ❑Medical Waste Facility <br /> Tattoo/Body Piercing SOLID WASTE <br /> ❑Waste Tire 9 <br /> ❑Complaint ACCOUMING <br /> ❑Other(Please Specify): <br /> 10 <br /> ***BOXED AREA-EHD USE ONLY*** <br /> /1 I <br /> Records provided by Staff-PPR Complete. staff Name: /ligIfCi Das-os <br /> 1868 E. Hazelton Avenue Stockton, California 95205 T 209 468-3420 F 209 464-0138 www.sicehd.com <br />