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01/28/2062 13:29 20946711 <br />DATE RECEIVED <br />A UIN COU <br />ENVIR011 <br />\f 304 EAST WE <br />'C12 JINA 2� P� 51 ST( <br />PUBLIC RECOR[ <br />AGE STOCKTbN rFa� jai LL <br />HEALTH SE DICES EHD LOG NUMBER <br />YPUBLIC <br />AL HEALTH DIVISION <br />t AVENUE, THIRDIfi`, <br />TON CA 95202 ?; 5 . / L/ <br />9) 468-3420 <br />RELEASE APPLICATION <br />APPLICANT a\V (A7 2. RUSIN <br />TSS1AG5NCYd&mffed CkeeF-wyliwafiE6 <br />ADDRESS R32 SAIao Rood <br />PHON1064010- — OO FACSIMILE'12 <br /><h I ENTATIVE' APPOINTMENT DATE <br />/7 <br />TIME FF <br />(Please give Ito 10 business <br />CHECK BOX TO EXPEDITE REQUEST. E7 D FEE - REQ <br />days from date of application submittal) k <br />21 if <br />JEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT <br />DATE g OZ <br />FIL <br />E ADDRESS <br />VI l) 'Mtf <br />i <br />- <br />1 <br />ENVIRONMENTAL <br />HEALTH DIVISION FILES JAI 31 200' <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HO <br />OTHER CLEANUP SITE (NON -LOP) ❑ FO <br />UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ DO <br />HAZARDOUS WASTE GENERATOR O CHI <br />TIERED PERMITTED FACILrIY ❑ MO <br />q TATTOOIBODY PEIRCING ❑ PO <br />❑ MEDICAL WASTE FACILITY ❑ PU <br />SING ABATEMENT ❑ SOLID WASTE FACILITY <br />D FACILITY ❑ SOLID WASTE VEHICLE <br />KENNEL ❑ DAIRY <br />KEN RANCH ❑ PKG TREATMENT PLANT <br />ELIHOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br />LISPA ❑ LAND USE APPLICATION 31TES <br />LIC WATER SYSTEM ❑ OTHER (PLEASE SPECIFY ABOVE) <br />1. List up to ten addresses in the space all <br />the appropriate box(es). At least one fila <br />e. Select the type(s) of files from the list above by checking <br />ype MUST be selected. Fax to (209) 464-0138 or mail to the <br />address indicated above. <br />2. EHD will notify the applicant if any EHD fi <br />approximately five business days but no <br />will be hold for a maximum of five business <br />es exist. An appointment for review will be confirmed <br />later than ten (10) days after receipt of application. The files <br />days for review. Appointments should be scheduled <br />accordingly, <br />3. A file that is actively being worked on by <br />HD staff may not be immediately available for review. A new <br />application may be submitted when the fils <br />4. Any file not retumed In the same COnditioi <br />is available. <br />as released will be reorganized by EHD staff at the expense <br />Of the applicant. Future file reviews by the <br />same applicant may require a $78.00 deposit prior to review. <br />5. 'TENTATIVE appointment dates must be <br />confirmed wlth EHD staff. <br />6. Applications received after 3:00 pm will be <br />processed the next business day. <br />CONFIRMED APPOINTMENT DATE <br />TIME <br />DATE CONFIRMED <br />PHONE FAX INITIALS <br />REVIEWED YES NO <br />REVIEW DATE <br />