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REC <br />I._1 V E • <br />SAN JQAQUIN COUNTY ern, Loc NWBra <br />MAY 0 9 2012 ENWRONMENTAL HEALTH DEPARTMENT <br />1868 E=ast Hazelton Avenue, Stnckt0n, CA 9520"232 1 <br />Telephone: (209) 468-3420 Fax. (209) 464-0138 Web: y.Sjg0v.Org/ehd <br />ENVIRONMENTAL HEALTH <br />I'ERMiT/SERVICES <br />PUBLIC RECORDS RELEASE APPLICATION <br />. —.____— A A.. A .... ._• <br />ADDRESS: 2 [)(} <br />PHONE (1):PHONE (2), <br />vE°AP01NTMENT <br />DATE: <br />(Plawm allow 10 bu$uleW days <br />from date of awication gut <br />©CHECK BO>O To EXPEAI7E REQV ' - $1j2'Ff GHECrt <br />SIGNATURE OF APPLICANT <br />Electronic information: El List Cl Man <br />r4. <br />Street Nam"`IV <br />***Please respond as soon as possible. <br />g I need to notify applicant during week of 5/14/12 if <br />7. EHD has files for listed addresses or not. <br />8. <br />10. <br />Siwcitie pat" FRa�ge of Inlormotion Repu"clad: From <br />�YN�OI <br />UFROROUW TANK (UST) CLEANUP SITE (ID&) <br />-OTHER CLEANUP TE (t1aN,LOp) <br />UNI)ERGROUND TANK (M1 MTORINOIREMOVAI) <br />HAZARDOUS WASTE GENERATOR <br />TIERED PERMITTED FACILITY <br />J MEDICAL WASTE FACILITY <br />WELL AND SEP'nC PERsIr- RECORDS ARE <br />i1NESS/AGENCY.E� fS10ii-7 %Af( <br />CiTYISYATEJ IP:A(IAAoiz) ?' IT/0 <br />p <br />_ FACSIMIt P: 7 q.2.5 - <br />Time: <br />-_—_�e��ve` .-only m�thaco,girniedJ <br />"LY)- REQUEST PROCESSED Rv 3B DAY$ <br />DATE 2 <br />I Fow FAciurr <br />1 Dec ISI, <br />I CHICKEN RANCH <br />MOTELIHOTEL <br />pOOUSPA�n���� <br />COWLAW RECORUS <br />FOR REVIEW: MONDAY-FRIOAY <br />_ to <br />© S MWASTE FACILITWVENIG,E <br />El WASTE TIRE <br />El DARY <br />❑WAstewATERTREEAtwNTpLANr <br />pt>r nR TRUCK/YARD/CK=AL TOLE178 <br />® LAND UsEAmucArm sm <br />® OTHER (PLEASE SPEC M <br />1. Int u ip ten„addresses bi ifte Space above. Select the �Y mm-wrnt MCLUOING HOLIDAYS) <br />b0x(es). At least one file type MUST be Selected. F tYDets) of files from the h$t above by checking the apprOpflate <br />ra ” will not be p ax to -(2096 43�-Q131 "r wait to the ' ldi above'. Address <br />accepted - for additional assistance with fate addresses, Contact <br />3200 pm will be processed the next buainesa day. tt6e EHD. Applications received after <br />2- The EHD will notify the applicant If any EMD Blas exist An appointment for review will be confirmed approximately ten (10) <br />days after receipt Of application. The files will be hold for a maximum of five <br />should be schaduied accbusiness days for review. Appointments <br />ordingly. <br />S. A file that is actively being worked on by EHD staff may not bs inernedia�ly avaifa6No eor review, A new <br />submitted when the fae is available. appNcation maybe <br />4. Any Nie not returned in the same cLxWltton as reieasod Witt <br />Future Lila reviews be re0rganIZ0d by EMD staff at the expense of the applicant <br />by the same applicant may requhe a S12S deposit prior to review. <br />7 <br />