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�1 urs «�L+ 111:q 2d9-579-2225 <br /> MODESTO ATC <br /> DATE RECENEC) PAGE U1 <br /> n5LD i1i�i�iI�`� � `LN�!aAQ'UIN COLWTy40 <br /> EHD LOCI NUMBE <br /> � D <br /> EN uRoNIV.LENTAL MALLTH DEPART-NM NT <br /> 304 E Weber Ave 3`d Floor Stockton, CA 95205 <br /> SEP 0 1 2004 (209)468-3420 Fax: (209) 4-64-0138 Web: www.co.san-joaquin.ca us/ehd. <br /> Iq <br /> �=iu�',�.,iti�ivlENT HEALTH <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: ()('(w Qo,, A4., qU&1NEBS/AC3ENCY: ATQ- <br /> Amass: ( L�w+� p4tw,•. S��}-� a <br /> PHONE: Z,,� I SJ-1 '" Z�LI FACSWIL : -L..O1i S 74 <br /> TENTATIVE*APPOINTMENT DATE: t' l Time: q Q c) F <br /> (Please allow is buatnrss days from date of application submittal) J <br /> �•�t !Y i' % <br /> U CHECK BOX TO EXPEDITE REQUEST•$83.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT / <br /> 6JOTE'. 0,ri -j L & 1�iS �` S i S -fir ra,•►�� L�fYDATE <br /> Dep8r4YTerlt Use Onto <br /> FILE ADDRESS VNIT <br /> 1. SI-1 5 att i� Ve..� Cxy <br /> S Ck +U�f JAZ, q1X <br /> z s�i 5{5'1 Qt,1. 0- 4,�.rL a I uG Hi----i, ❑ Unit 1 <br /> a. Sir" Ca �•y c v c i.x . S�Lk �' <br /> .. `fi S 4� 'I' yi 2 ;ln;7I <br /> e. <br /> Strait Z l rt,��t^, Ca d, a Jilt► Unit 3 <br /> a 5�r.ea c.%V <br /> e. au"i 3Zj 14, nit <br /> �- - cay 5 t.. �1 <br /> ,�. 9�..� r 5t Ntv6L4, ❑ unit 5 <br /> ENVIRONMENTAL HEAL <br /> TH bEpAR7M <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) C3 HOUSING ABATEMENT © SOUD WASTE FAkiTY <br /> I� OTHER CLEANUP SITE(NON.LOP) 0 FOOD FACILITY d SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONrroRING REmovAL) ❑ DOG KENNEL d DAIRY <br /> hr HAZARDOUS WASTE[GENERATOR 0 CHICKEN RANCH D PtCG TREATMENT PLANT <br /> TIERED PERMITTEb FACILITY 0 MOTELMOTEL 0 PUMPER TRUCK YARDfCHFM TOILETS <br /> TATTOWBODY PIERCING M POOL/SPA M LAND USE APPLICATION S1TE8 <br /> ❑ <br /> MEDICAL WASTE FACILITY CO OTHER(PLEASE SPECIFY) <br /> �• List up to ton addresses In the space above. Select the type($)Of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to( 1 4N40, 38 Or mall to the <br /> address indicated>« v �Q$ , <br /> 2, EHd will notify the appilcant If any EHD files exist. An appointment for review will be confirmed <br /> approximately five business days but no later than tan (40) days after receipt of application. The files <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 ne% <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 EHD staff at the expense <br /> of the applicant. Future file reviews by the same appllcant may require a$93.110 deposit prior to revlev <br /> S *TENTATIVE appointment dates must be confirmed with EHD staff, <br /> $• Applications received after 3:00 pinwill be processed the next business day, <br /> =YES <br /> MENT DATE - TIME - <br /> PI�QNtw FAX- ' ` . ' '.°:INfrIALS <br /> NO REVIEW DATE ! <br /> �nnani <br />