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1Jy/1J1/2UU4 12:41 2b9-579-2225 MODESTO ATC PAGE U1 <br />DATE RECEIVED EHD LOG NUMBE <br />Nil <br />DD SAN JOAQUIN COUNTY � tl� I J; ,�S E+ NVIRQNIviENTAL HEALTH DEPARTMENT <br />SEP 0 1 2004 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br />(209) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd <br />EI VIR,, [VIENT HEALTH PU13LIC RECORDS RELEASE APPLICATION iq <br />APPLICANT: ���W �i0.H A4- BUSINES&AGENCY• AT� <br />ADDRESS: <br />PHONE: Z,,-) I 7 -?-'Ll FACS IL Z- ° y S' 79 - Z -L7 -r <br />TENTATIVE* APPOINTMENT DATE: Tuna: O O <br />(Please allow 10 business days from date of application submittal) <br />CHECK BOX TO EXPEDITE REQUEST - $93.0`0'FES -/ REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT D v �- Pik DATE <br />L<)t �I r sos -E-4ko4-451• l 3',Mwl, frpt <br />1� <br />1�Y <br />9�rf Zv <br />Department Use Only <br />UNIT <br />Unit 1 <br />djInQ <br />XUnit 3 <br />�nit <br />%r --\n Unit 5 <br />d �s <br />v -, <br />ENVIRONMENTAL HEALTH DEPARTM <br />_P <br />�I UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />HOUSING ABATEMENT <br />FILE ADDRESS <br />C2 OTHER CLEANUP Sr E (NON -LOP) <br />O <br />1. <br />strw <br />5'00' <br />s 1�c.K <br />u5t t4,11Z. <br />z <br />S&W <br />5( SI <br />4t. L( k-A1f4-a <br />S <br />❑ <br />MOTELIHOTEL <br />❑ PUMPER TRUCKtYARD/CHEM TOILETS <br />❑ TATTOOIBOOY PIERCING <br />In <br />POOLISPA <br />In LAND USE APPLICATION SITES <br />4. <br />❑ <br />t,1t-\ tt Aq l,aA c., <br />S GV- <br />40 -1 'q S i hZ <br />e. <br />strw <br />Lo L <br />Q, /M4 %^ 34-1Nij. CKY <br />$ CK <br />-' <br />e. <br />Street <br />- �: k <br />1J rA,,&t L% (4 d. cty <br />/ulr3 <br />L-% <br />7. <br />c�3 <br />(A. c1kILO•. city <br />e. <br />sa..1 <br />-5Z3,r-) <br />N, kr,4 - hO-L <br />S t_k <br />9. <br />3trm1 <br />10. <br />street11q5"Si <br />L Y dti cayS <br />L <br />1�Y <br />9�rf Zv <br />Department Use Only <br />UNIT <br />Unit 1 <br />djInQ <br />XUnit 3 <br />�nit <br />%r --\n Unit 5 <br />d �s <br />v -, <br />ENVIRONMENTAL HEALTH DEPARTM <br />_P <br />�I UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />HOUSING ABATEMENT <br />O SOLID WASTE FAdkiTY <br />C2 OTHER CLEANUP Sr E (NON -LOP) <br />O <br />FOOD FACILITY <br />C3 SOLID WASTE VEHICLE <br />W UNDERGROUND TANK (MONITORINGMEMOVAL) <br />❑ <br />DOG KENNEL <br />O DAIRY <br />hr HAZARDOUS WASTE GENERATOR <br />O <br />CHICKEN RANCH <br />13 PKG TREATMENT PLANT <br />1? TIERED PERMITTED FACILITY <br />❑ <br />MOTELIHOTEL <br />❑ PUMPER TRUCKtYARD/CHEM TOILETS <br />❑ TATTOOIBOOY PIERCING <br />In <br />POOLISPA <br />In LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY <br />❑ <br />OTHER (PLEASE SPECIFY) <br />1. List up to ten addresses In the space above. Select the type(s) of flies from the liat above by checking <br />the appropriate box(es). At least one flie type MUST be selected. FM12 2031 464-0138 or mall tolhQ <br />address Indicated a ve. <br />Z. EHD will notify the applicant if any EHD flies exist. An appointment for review will be confirmed <br />approximately five business days but no later than ten (10) days after receipt of application. The flies <br />will be held for a maximum of five business days for review. Appointments should be scheduled <br />accordingly. <br />3. A file that is actively being worked on by EHD staff may not be immediately available for review. A no% <br />application may be submitted when the file Is available. <br />4. Any file not returned In the same condition as released will be reorganized by END staff at the expense <br />of the applicant. Future file reviews by the same applicant may require a $83.00 deposit prior to reviev <br />S. *TENTATIVE appointment dates must be confirmed with EHD staff. <br />6. Applications received after 3:00 pm will be processed the next business day. <br />CONFIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED <br />REVIEWED . <br />YES NO <br />PHONE FAX ' INR1Al.S <br />REVIEW DATE <br />