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.eo-Pha viro taoc. FAX NO. : 2095690295 Mar. 26 2002 09:49AM P2 <br /> N pAQUIN COUNTYPUBLIC HEALTH SERVICES <br /> "`•':i `A- f�NVIRONMENTAL HEALTH r)IVIS10N <br /> THIRD FLOOR <br /> ' 3034 40202 <br /> 02 �!• 2F. A'r9 8 43 <br /> PUBLIC <br /> f9f1�rRECORDS RELEASE APPLICATION <br /> APPLICANT <br /> _7^Iod@M1d•ryf/iro)"f� BUSINESSIAGENCY_61017/dy4Se <br /> ADDRESS a 3 d ,t,* y Avg <br /> PHONE 3 6y Oa9 3 .__FACSIMILE <br /> TENTATIVE'APPOINTh1ENT DATE f� TMC �LO�I. <br /> (PlcasO ei 7 �10 U/}t�es• rom Iapplic On su61n z) <br /> J� •CHECKBOXTO,FJCPEpREREQUEST•$07. OFE R UEST PROCESSED IN USINESS DAYS " <br /> SIGNATURE OF 4PPLICANT DATE" 2 <br /> 4FawIL)EYADCDdRrES_S Cd•I•-r7+d./SSr/O�r',y <br /> THIS SIDE EHD STAFF USE ONLY <br /> 17 PROGRAM ELEMENTS SEARCH <br /> jam e rol5F <br /> t __ <br /> O1 <br /> N a� as T eTir/. <br /> S ' <br /> P <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) O HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> O OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> }�UNDERGROUND TANK(MONITORINGIREMOVAL) 0 DOG KENNEL Q DAIRY <br /> ❑ HAZARDOUS WAS •E GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> O TIEREO PERMrfTS13 FACILITY ❑ MOTEUHOTEL ❑ PUMPER TRVCK/YARD/CHEM TOILETS <br /> ❑ TATTOOIBODY PBIRCING ❑ POOL/SPA ❑ LAND USE APPLICATION SITES <br /> ❑ MUOICAL WAST8 FACILITY 1 ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ADOVE) <br /> 1. List up to ten 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 file type 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 files exist. An appointment for review will be confirmed <br /> approximately five business days but no later than ten (10) days after receipt of application.-The fifes <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 new <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 /> S of the applicant. Future file reviews by the same applicant may require a$87.00 deposit prior to review, <br /> "TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6• Applications received after 3:00 pm will be processed the next business day, <br /> I , <br /> ' CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX <br /> INITIALS <br /> REVIEWED ., <br /> en .. x aaavoo YES NO REVIEW DATF <br />