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MCEIVED <br /> SAN,-JOAQUA& J �6!3 9 ¢� <br /> . I€a <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> s E MRO MEN A( REALTH <br /> mess gr.�t�i.� <br /> PERMIT/SERVICES 1_51 <br /> EHD LOG NUMBER: '37qO7 <br /> APPLICANT: S se-A BUSINESS/AGENCY: F_" (_ <br /> ADDRESS: ql- CITY/STATE/zip: Wg4fi 6n I M,-0 �A S <br /> PHONE(1): 6i5 S'�? P ONE(2): FAX OR E-MAIL: M o_rj'r�uS D f 5�� (� <br /> Please allow 10 business days from date of application submittal for the records to be available. c vny -i/-Cb w, <br /> Staff will contact you to arras ap . ment date and time to review the requested records. �J <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 infoCaD_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 <br /> HEALTH DEPARTMENT FILE ADDRESS d4 le 5, 0`` t--3 H <br />\°t FILES (Specific addresses only,address ranges will not be accepted) EHD USE ONLY <br /> Underground Tank(UST) Street# Street Name City <br /> CyI anup Site(LOP) �rt4 '5_T �, Z ��e ❑CONSUMER <br /> [ Oth Cleanup Site(Non-LOP) f R(y, Cis c <br /> azardous Waste `ik�_l i��t777 tai ❑DAIRY <br /> Tie Permitted Facility z �. <br /> Aboveground Tank <br /> ST (Monitoring/Removal) ❑PWS <br /> az dous Materials 3 <br /> Spill/Release Response <br /> Solid Waste Facility/Vehicle 4 R'TJVATER QUALITY <br /> Food Facility <br /> ❑Pool/Spa SrrE MITIGATION <br /> E]Dairy 5 <br /> n Land Use Application Sites <br /> Septic Pumper Truck/ s ❑HOUSING <br /> Yard/Chemical Toilets <br /> F1 Wastewater Treatment Plant QjPA <br /> Housing Abatement 7 AST/HM I HW <br /> Motel/Hotel <br /> Chicken Ranch/Dog Kennel �CUPA <br /> F1Medical Waste Facility 8 UST <br /> TattooBody Piercing <br /> ❑SOLID WASTE <br /> Waste Tire 9 <br /> EI Complaint <br /> Ej other(Please Specify): ❑ACCOUNTING <br /> io <br /> ***BOXED AREA-EHD USE ONLY*** <br /> '31-t16 `cut t�K • ,A Ai-,e-k d t,A <-- ern e' t" - <br /> a kt! <br /> ❑ 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 F 209 464-0138 1 www.sjcehd.com <br />