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Ittlaw R.1CER LJ <br /> DATE RECEIVED EEL LING t1UK+teE'n <br /> � DEC � SAN JCtAt]ufrd COUNTY <br /> E� �01� ENVIRONMENTAL HEALTH DEPARTMENT <br /> ;1368 East Hazelton Avenue. Smcktan, CA 95205-5232 <br /> PMRCINMENTALHEA-je�lephone: 1209,1 463-3a20 Fax:(2091 484-0133 Web: v;orw.5jgov.orgrah0 <br /> PE-PM:`T/SEpt"'CFS PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: Chris Qlsen <br /> BUStNESS'AGENCY: <br /> ADDRESS: rimavera Rd CITYtSTATEZP: boUlder Creek, CA <br /> PHONE(1); 8J1-2b2-88,59PHONE{2): FACSIF ILE: <br /> Please allow 10 business days from date of application submittal for the records to be available, <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑L'N ELI:HJ%:G E>fiL-DITE AEGLIEST �1.'s]FEE iC.A�H Ga':ttEGK OIL\'I-FlEUiic`iT r qQ;E �_IN S aW zlf�E=5 QAYS <br /> SIGNATURE OF APPLICANT r ��r �; DATE <br /> i1 <br /> Electronic Information: [i List[I Map-Description: <br /> FILL ADDRESS <br /> Sae�t r Suez!IL-me <br /> USE ONLY <br /> t 1es# e a a# rov �� 5 <br /> 2. r Unit 1 <br /> 3. <br /> `I Unit 2 <br /> 4. ` <br /> — ❑Unit 2H <br /> 6. <br /> Unit 3 <br /> 7' [Unit-0 <br /> 8. ITE MITIGATION <br /> 10. <br /> n unit 3 I <br /> Specific➢ata Range of inlormaUon Requested: From to <br /> ENVIRONMERTAL HEALTH DEPA TrtENT FILES <br /> UNX-RGR.7JAD TAm(UST)CLEAAuY ST(LOP) C MENIAL WAST FACILITY ❑SOLID WASTE FALCIU VE}tict F <br /> OTHER CLEANUPSrTE Nett-LOP IC,0 hj t(/1 <br /> ( I Cr��H 0.islvG ASArrr_r,� ❑WASTE TI:tE r , <br /> UNDFY.GR0JmD TA.-w..(MOMTCRers'F EMCIVAL)l U Fouc.FACILITY ❑DAIRY 114?) I 5 <br /> ABOvEGRbJND TAkK �� CHIC%`N RANDO DSc.K_i 4AEL ❑WASTEWATER TRTMEN gal <br /> _) <br /> HAIIiAD SW"TE%r-7APDNSMrrEpiAtsr; MOTEEUHOTE-- []PLurzaTRurr.:Y,ean!D1EI4CALTo-LE-3 <br /> TLRtm R-p-miTrEe FA:'r Ry [_..'P0L--'SPA f❑�LAhD USE APRLCATION SITES <br /> Irl TATToo-&ooy PERaYG �J COiV1L .AITi RESP04Se RECORDS L-_l 07JER{PLEASE SPECUPY1 <br /> WELL AND SEPTIC PERFAIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AI -5MPM(EXCLUDING HOLIDAYS) <br /> f. List up to len addrocses in the space above. Select the Iype(s)of tiles tram the list above by checking the epprepriale <br /> box(esi. At least one tile type MUST be selected. Fnv to f2?1414r4.Di38 pr mr3p to the?ddracc irv{N-ated ebrve Address <br /> ranges will not be accepted.Appricalions receivpd after 3:00 pm will be proces5ed the next business day. <br /> 2 For asslslance in identifying the nature and content of EHD records.please contact EHD at the number noted above. <br /> 3. The EHD will notify the appticant if any EHD files exist. An appointment for review will be confirmed approximately ten ilei <br /> days after receipt of application. The tiles will be held for a maximum of five business days for review- Appointments <br /> should be scheduled accordingly. <br /> 4. Anyfile not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. <br /> Future rite reviews by the Lorne applicant may require a$t30 deposit prior to review. "`BOXED AREA-EHD USE ONLY`-' <br /> i' <br /> ❑ Records provided by Staff-PPR Complete.Staff 143me: <br /> w.� 71 11 <br />