Laserfiche WebLink
9/17/2008 16:07 5165647. KRAZAN PAGE 02/02 <br /> IT EHU LOG NUMBER <br /> E; SAN JOAQUIN C�OUNTY <br /> ENVIRONMENTAL HEA1, "ji Diu.4,RTMENT <br /> y;P 1008 600 East Main Si:7-aat, Stocktvi, CA.957022708 <br /> M Teleptionc, (209)468-3420 Fax: (209)464-0133 Web: www,kjgov.org/chd <br /> �i..�`s/IYJ i:{{�ii' il'u i §"flr�''+,t_. <br /> PU13LIC RL CORDS RELEASE APPLICATION <br /> APPKLJICA T: BUSINESSIAGENCY:.e-1 <br /> ADDRESS- Ac 0_44�4vl_cd <br /> 7 <br /> 7 P ON <br /> PHONE(i): H C(2): _FACSIMILE; <br /> TENTATIVE"APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application sybrnittil -'Tentative only-must be confirmed) <br /> XCHECK PDX TO EXPEDITE REQUCST-�$9�8 (CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUVNESS WDAY$ <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic Information- E] List El Map-Description: <br /> FILiW ADDRESS EHD USE ONLY <br /> stre4t# Street Name city unit I <br /> El UnIt.2 <br /> WUnit 3 <br /> Unit 4 <br /> 11 Unit 5 <br /> 8. <br /> 10. <br /> Specific Date Range of information Requested-. From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> LID WASTE FACILITWVEHIQ�E <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 HouslNo ABATEME14T SOLID <br /> 5 OTHER CLEANUP'SITE(NON-LOP) M F000 FACILITY /0 ISCASTE TIRE <br /> �5 UN0rRQRQUNDrANK(MONITORINGIR5MOVAL) 0 06r,KFNNEi. 0 DAIRY <br /> AZARDOUS WASTE GENERATOR 0 CHICKEN RANCH 173 WASTEWATER TREATM ENT PLANT <br /> _ tERrm PERMITTED FkCILETY 0 MOTELMOTRI, 0 PUMPER Tr,1JCKfYAtjD/G HEM TOILETS <br /> 13 TATTOO100DY PIERCING r] I`00Lt$PA 12 LANti Use APPLICATION SITES <br /> C MEDICAL WASTE FACILITY 0 OTHER(PLEASE 3P CIFY) <br /> WELL AND SE"G PURMIT RECORDS ARE AVAILABLE FOR REVIt W -MC NDAY-FRJDAY 0;00 AM-5.00FM - EXCLUDING H041DAY5. <br /> 7, List up to ten addresses in tho space above. Select the jypp(s)of files from the list above by checking the appropriate <br /> box(es). At least one file typo MUST be Selected. Fax to(209)46 -4138 or mail to the address indicated above. Addruss <br /> ranges will not be accepted-for additional assistance with file a dresses,contact the EHD.Applications received after <br /> 3,00 pm will bo processed the next business day. <br /> 2. The FHD will notify the applicant if any EHD filos Pxist. An appointment for review will be confirmed approximately ten (10) <br /> days after receipt of application. The files will be held for a maximum of five business days for review- Appointments <br /> should be scheduled accordingly. <br /> 3- A file that is actively being worked on by EHD staff may not be immediately available for review. A now application may be <br /> submitted when the file is available. <br /> same-_" - --will- - -—__­­-__ _F_ -if __ -U xpimc 1156iaffli _nt- <br /> ,f,'_An_yfilo_ not returned In the Condition as released he re by Ifo tiX M he e of <br /> Future file reviews by the same applicant may requiro a $98.00 deposit prior to review. <br /> EHD USE ONLY <br /> If you should need further assistonCC please contact Diane MikrtinCZ @ (209)468-3425 directly, Thank You` <br />