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LL60'ON INVL9102 'yl 'lni 1WIl paAIa3a� <br />bA [ EHD LOO NUM6ER <br />SAN SDAQUIN COUNTY <br />JUL ENVIRONMENTAL HEALTH DEPARTMENT <br />1869 East Hazelton Avenue, Stockton, CA 95205-6232 <br />' EPMROKMENTAL HEAfTI-I Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.SJgov,a •g/ehd <br />! PEPU IT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT- Va ELSIN123SlADENCY:_ <br />AbPRESS: SBI40 Hill Si 5ul*5 — CITY1S;ATF1ZIP:__ Pq -Z <br />PHONE (1): :i t S-. °��i- ql�� PHONE (2): FAX OR E -MAIL: _��ta��-�Cottve��C4rl5t?����. t• <br />Please allow 10 business days from date of application submittal for the r€ co -ds to be available, <br />Staff r ill contact you to arrange an appointment date and time to review th a equested records. <br />[� CHECK SOX -0 EXPEDITE REQUEST - $130 PEP, (CASH OR CHECK ONLY) - REQUEST PRO :ESSED IN 3 8USINESS DAYS <br />SIGNATURE OP APPLE 3ANT e o DATE 1 IS 116 <br />1.: List up to ten addr . ses in the spaL- below. Seloct tho types) of files from the list beic A by checking the appropriate <br />box(es). At least c ie file type MUST be selected. Pax t® to the ithi teas lndle ated above. Address <br />ranges will not be Iccepted. Applications received after 3:00 pm will be processed the r le Et business day. <br />2.i For assistance In I lentlfying the nature and ccntant of EHD records, please contact Ftti) it the number noted above. <br />3, The EHD will notif; the applicant If any EHD files erlst. An appointment for re�aiew will Ise confirmed approximately tett 110) <br />days after receipt I f application. The files will be held for a Maximum of five business Ila fs for review, Appolntments <br />should be schedul rd accordingly. <br />4. Any file not return, -d In the same condition as released will be roorganizad by EHD staff' a t the expense of the applicant. <br />Future file revlews by the same applicant mew require a $130 deposit prior to review. <br />WELL AND SEPTIC F ERMIS Rr.COPDS ARE AVAILABLE FOR REVIEW, MONDAY-PRIDAY 8:00A1 I-5:00PM (EXCLUDING HOLIDAYS) <br />Edectr®rlBc inforrnat Dn: ❑ List ® Map ® Description: <br />o:. <br />Specific Date Ran, a of Information Requested: From to <br />E:EALTH DEPARTMF NT FILE ADDRESSEHD USE ONLY f-13 <br />FILES ry (� <br />UNDERGROUND TANK (UST) straot o Street Name cit.' -7^' L b� <br />CLEANUP SITE (LOP) ��� [y I y'Tq CONSUMER <br />E HAZARDOUS WASTE <br />rTIeRLD PERMITTED FACILITY <br />ABOVEGROUND TANK <br />UST (MONITORING I REMO% .L) <br />HAnROOUS MATER.IALs <br />SPILURI;LEASE RESPONSE <br />$OLID WASTE FACILITY <br />l.!.! FOOD FACILITY - <br />O <br />POOL/ SPA <br />DAIRY <br />LAND USE Aoo110 n, N !TI ? <br />[�] S[PTIO PUMPER TRUC <br />• YARD / CHEMICAL TOILETS_ <br />WAGTEWATER TREATMENT I .ANT <br />HoUSINOADATEMENT <br />MOTEL/HOTEL <br />CHICKEN RANCH / Doe KED IEL <br />std MEDICAL WASTE FACILITY <br />TATTOOI80t)Y PIERCING <br />WASTE TIRE <br />COMPLAINT <br />QTHER(PLBASE SPECIFY)! <br />—130 -D AREA -tHp USE ONLY""' <br />F(CUPA: <br />WA.TE <br />® ACCOUIMNG <br />L00/1.00'd 9L9L4: LO:ZL <br />r <br />i <br />i <br />I <br />as <br />9LOc,GL/Lase <br />1 <br />13 DAIRY <br />2 <br />25a ( <br />�l r` � S�c�� <br />picall, ®� <br />(ULA (UW , <br />® ® PW® <br />z�� e <br />p►= I; <br />[� WATER QUALITT _ r. <br />I v1 <br />Br_ Z 6 "t <br />4 <br />Pi/�BI��cr� <br />IRS <br />gSITC MITIGTION l <br />CJ <br />190 <br />P;e�ll a <br />_ <br />e2A10 <br />1 <br />1 <br />tie <br />h HoVP.^,IND <br />Vu� ` <br />0 <br />i/ten'� <br />N�f ce// I <br />_ <br />OUPA <br />—130 -D AREA -tHp USE ONLY""' <br />F(CUPA: <br />WA.TE <br />® ACCOUIMNG <br />L00/1.00'd 9L9L4: LO:ZL <br />r <br />i <br />i <br />I <br />as <br />9LOc,GL/Lase <br />