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dy/01/2UU4 12:4r 2d'J-579-2225 MODESTO ATC PAVE d1 <br /> DATE RECEIVED EHD LOG NUMBE <br /> ,=�I;� I� 0 SAN JOAQUIN COUN'T'Y <br /> - E+ NV ROHM ENTAL HEALTH DEPARTMMNT <br /> 301 E Weber Ave 3`1 Floor Stocktox4 CA 95205 <br /> SEP 0 1 2004 (209)468-3424 Fix- (209) 464-0138 Web: www.cv.san-J'oaq u'a.aa.usfehd <br /> LidV,�,-AI[J/SF2]ENT Q HEALTH <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: ._ Q f,(-w V o,H A4" _IlUSINESSIAGENCY: AT(?" <br /> ADDRlFss: <br /> PHONE: 'S� 1 �7 ~ 7.7-'-t FACSIMIL : -L-,01 S �-9 - ?-L,-u ` <br /> TENTATIVE*APPOINTMENT DATE. � 6 Tim*: <br /> 1 / <br /> Meaae allow 10 businoss days from date of application submittal)In ivy` i <br /> CHECK BOX TO EXPEDITE REQUEST-U3100 FEE-R/EQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE ��`�A 4 � <br /> S i S +4APa-%5%N (,` "!)lU`Jff �'� Deparlmant Use only <br /> FILE ADDRESS UNIT <br /> 7 <br /> z saw /�, 0 unit <br /> e, aa.,s Unit 3 <br /> a. av x C, IkCS tti I^ <br /> 7. §Yr. ca 5 trod c.IL�c� nit 4 <br /> Unit 5 <br /> �, ia. se.et f Sti LY'dy cid, a'1 S �- <br /> ENVIRONMENTAL HEALTH DEPARTM <br /> €P� <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) M HOUSING ABATEMENT O SOLID WASTE FA6 <br /> O2 OTHER CLEANUP 917E(NON-LOP) Q FOOD FACILITY C3 SOLID WASTE VEHICLE <br /> W UNDERGROUND TANK(MONITORING/REMOVAL) 0 DOG KENNEL 0 DAIRY <br /> !Rf HAZARDOUS WASTE GENERATOR a CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY 0 MOTELIHOTEL d PUMPER TRUCIUYARDICHEM TOILETS <br /> ❑ TATTOOIBODY PIERCING d POOLISPA 0 LAND USE APPL.ICAT16N srms <br /> ❑ MEDICAL.WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> 1, List up to ton addresses in the space above. Select the type(s)of files from the list above by checking <br /> the appropriate box(es). At least one fila type MUST be selected. 'Fax to 82140;9138 or mall to Int <br /> address Indicated a ve. <br /> Z. EHD will notify the applicant If any EHD files exla L An appointment for review will be confirmed <br /> approximately five business days but no later than tan (10) days after receipt of appliCaltian. The tiles <br /> will be held for a maximum of f#ve 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 filo is available. <br /> 4. Any fife not returned In the same condition as released will be reorganized by EHD staff at the expenal <br /> of the applicant. Future file reviews by the same applIC2nt may require a$93.00 deposit prior to revlev <br /> S. *TENTATIVE appointment dates must be confirmed with END staff. <br /> 6. Applications received after 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME _ - — - . <br /> DATE CONFIRM E0 PHONE FAX- <br /> REVIEWED <br /> AX REVIEWED YES NO REVIEW DATE <br /> MO wawa. <br /> amass <br />