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K1=Ut1Vt:U <br /> SAN1.1-JOAQUiN OCT 11 2017 Environmental Health Department <br /> C 0 U 1\1 TY--- AONMEN PUBLIC RECORDS RELEASE APPLICATION <br /> AL FF <br /> Greatness grol,,,s hler(2, PEWIT/SlEWGIES <br /> C, EHD LOG NUMBER: <br /> 0�n Sdi",6'r• a (`Ga <br /> 7 �4 l� <br /> APPLICANT: BUSINESS/AGENCY: <br /> ADDRESS: r CITY/STATE/ZIP: U 2 <br /> 1 -2 - _'4 q, <br /> PHONE (1): -?;) PHONE(2): - FAX OR E-MAIL: <br /> -2.('�q <br /> Please allow 10 business days from date of application subnitalor the records to be available. c <br /> Staff will contac ou arraqappointment date and time to review the requested rpcor(4;. <br /> DATE -7 <br /> SIGNATURE OF APPLICANT 10 _jjQ 2 (/// <br /> 1. List up to ten addresses int 'qspace be-1`6w7Addre!Eis­ranges WILL NOT be accepted. Select the tyhti(sf/of files from the <br /> list below by checking the Zo ropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138,mail to the <br /> address indicated t—l—, =nmail to info(a)sicehd.com. Applications received after 3:00 pm will beproce d <br /> Id <br /> tue t <br /> business day. <br /> 2. For assistance in identifying the nature and content of EHD records, please contact EHD at the n <br /> '. FL bto y <br /> 3. The EHD will notify the applicant if any EHD fifes exist. An appointment for review will be confirmed approximately ten (10) <br /> days after receipt of application. The fifes will be held for a maximum of five business days for review. Appointments <br /> should <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: [:1 List[I Map-Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL <br /> FILE ADDRESS <br /> HEALTH DEPARTMENT <br /> FILES (Specific addresses onlyD M,address ranges will not be accepted) EHU ONLY <br /> underground Tank(UST) Street# Street Name city 1 <br /> Cleanup Site(LOP) 'NA I []CONSUMER <br /> rc <br /> ®'Other Cleanup Site(Non-LO _sf <br /> 2--flazardous Waste 7— DAIRY <br /> 2-Tiered Permitted Facility A', C <br /> Aboveground Tank <br /> [; VT (Monitoring/Removal) El PWS <br /> Hazardous Materials 3 <br /> lzSpill I Release Response — <br /> / 19 R QUALITY <br /> F1 Solid Waste Facility/Vehicle 4 <br /> F�Food Facility <br /> ❑Pool/Spa JUISITE MITIGATION <br /> F-]Dairy 5 <br /> E]Land Use Application Sites — <br /> F]Septic Pumper Truck 1 ❑6 HOUSING <br /> Yard/Chemical Toilets <br /> F1 Wastewater Treatment Plant N(CUPA <br /> n Housing Abatement 7 ASTIHMIHW <br /> F1 Motel/Hotel <br /> Chicken Ranch I Dog Kennel VuPA <br /> Medical Waste Facility <br /> 8 <br /> UST <br /> F-]Tattoo/Body Piercing MIC)LID WASTE <br /> [:]Waste Tire 9 <br /> F1 complaint <br /> E]other(Please Specify): El ACCOUNTING <br /> 10 'BOXED AREA-EHD USE ONLY... <br /> IL <br /> AA <br /> D Records provided by Staff-PPR Complete. Staff Name: EHD 48-06 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 IF 209 464-0138 1 www.sjcehd.com <br />