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mcutfvtu <br /> SAN ) O A Q U I N OCT 11, 2017 Environmental Health Department <br /> C 0 NTY--E-WRIONAfFWALHEXTH PUBLIC RECORDS RELEASE APPLICATION <br /> Greatnesscrows hlere. PEMM1T5ERMCE9 <br /> • JL��n .SL�I Cin 4ztcQsSOG1z' � 7u <br /> •C1. EHDLOGNUMBER: � <br /> APPLICANT: JO I) -wi wn . BUSINESS/AGENCY: -T ty] <br /> ADDRESS; I� 1� (,�, rJy.2� 5)-Q,.�--�I CITY/STATE/ZIP: <br /> PHONE(1): PHONE(2):29_V�,2, FAX OR E-MAIL: <br /> Please allow 10 business days from date of application submittal for the records to be available. gsS�rc,a Fes. co <br /> Staff will Contac ou o arra geq appointment date and time to review the requested r cord . <br /> SIGNATURE OF APPLICANT DATE c ' <br /> 1. List up to ten addresses inffrI space be ow. Address ranges WILL NOT be accepted. Selectthe type(s)'of files from the <br /> list below by checking thep ropriate box(es). At least one file type MUST be selected. Fax to(209)464.0138,mail to the <br /> address indicated below,o mail to info(cDsicehd.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. 1 <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:o0PM(EXCLUDING HOLIDAYS) <br /> Electronic information: ❑ List❑ Map—Description: <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL FILE ADDRESS <br /> HEALTH DEPARTMENT <br /> FILES (SPecifc addresses only,address ranges will not be accepted) EHD USE ONLY <br /> E�<Indergmund Tank(UST) Street Street Name city <br /> Cleanup Site(LOP) A L ❑CONSUMER <br /> • g6ther Cleanup Site(Nan-LOP) 1 e"-4L-s(, . <br /> 2-11azamous Waste <br /> (r, N ! ❑DAIRY <br /> Q'rriered Permitted Facility 2 .7 ()� � � Cat) <br /> [?Aboveground Tank (((( 1�- <br /> L2'0ST (Monitoring/Removap O PWS <br /> Hazardous Materials 3 <br /> W[ 4 ill/Release Response <br /> Solid Waste Facility/Vehicle 11 WAAW.goeury <br /> ❑Food Facility <br /> 160 RV <br /> Pool/Spa nE 101116ATIOn <br /> Dalry a <br /> ❑Land Use Application Sites <br /> L]UousiNc <br /> F1Septic Pumper Truck/ <br /> 6 <br /> Yard/Chemical Toilets <br /> ❑Wastewater Treatment Plant CUPA <br /> Housing Abatement T ASTIHM IUW <br /> Motel/Hotel <br /> ❑Chicken Ranch I Dog Kennel UPA <br /> 6 <br /> Medical Waste Facility UST <br /> Tattoo/Body Piercing o�w WASTE <br /> Waste Tire g <br /> complaint <br /> Other(Please Specify): ❑Accounnnc <br /> 16 <br /> *"BOXED AREA-EHD USE ONLY— <br /> ❑ Records provided by Staff-PPR Complete. staff Name: EHD 4848 Ij <br /> t <br /> S <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 F 209 464-0138 1 www.sjcehd.com <br />