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ECEIVED <br /> SAN:JOAQUI p <br /> Environmental Health Department <br /> MAR 16 2016 <br /> A W COUNTY PUBLIC RECORDS RELEASE APPLICATION <br /> cgt,�oRa¢' Greatness grows her""" l,ii, <br /> EHD LOG NUMBER: <br /> APPLICANT: .9 L: BUSINESS/AGENCY: ,Y+2•= > <br /> ADDRESS: CITY/STATE/ZIP: © �- <br /> PHONE(1): PHONE FAX OR E-MAIL: l <br /> PI sae a allow 10 business days fro date of application submittal for the records to be available. <br /> Staff you t arrange ointment date and time to review the requested records. <br /> SIGNATURE OF APP L DATE <br /> 1. List up to ten addresses in the space below. r 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-)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 DEPARTMENT p y 9 p <br /> FILES (Specific addresses only,address ranges will not be accepted) EHD USE ONLY <br /> Underground Tank(UST) Street# Street Name City <br /> Cleanup Site(LOP) /� / ❑CONSUMER <br /> ❑Other Cleanup Site(Non-LOP) <br /> ❑ Hazardous Waste V ❑DAIRY <br /> ❑Tiered Permitted Facility 2 <br /> Aboveground Tank <br /> UST (Monitoring/Removal) ❑PWS <br /> Hazardous Materials 3 <br /> Spill/Release Response <br /> 1:1 WATER QUALITY <br /> Solid Waste Facility/Vehicle 4 <br /> Food Facility <br /> Pool/Spa ❑SITE MITIGATION <br /> Dairy 5 <br /> ❑Land Use Application Sites <br /> �, '^�' ❑HOUSING <br /> E]Septic Pumper Truck/ sY, <br /> Yard/Chemical Toilets bib f' <br /> ❑Wastewater Treatment Plant ❑CUPA <br /> n Housing Abatement 7 AST/HM/HW <br /> ❑Motel/Hotel <br /> Chicken Ranch/Dog Kennel ❑CUPA <br /> Medical Waste Facility 6 UST <br /> Tattoo/Body Piercing ❑SOLID WASTE <br /> Waste Tire g <br /> Complaint <br /> Other(Please Specify): ❑ACCOUNTING <br /> 10 <br /> ***BOXED AREA-EHD USE ONLY <br /> rouI A wik-K 0. Cpw U Cis 5; n mt E <br /> ti 21706 l koty out- CLQ& 1,kw R- V-Yo <br /> ecords provided by Staff-PPR Complete. staff Name: A, f 0 4-1JQ EHD"-06 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209464-0138 1 www.sjcehd.com <br />