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11/04/2011 14:33 8803080 PE1`1 PAGE 01/01 <br /> RECEIVED <br /> DATE RFrFIVPn COP <br /> ILE AN ..IOAQUIN COUNTY EHD LOG NUMBER <br /> V ® 4 2011 ENVIRONMENTAL HEALTH DEPARTMENT <br /> ENVIRONMENTAL HEALTH 600 East Main 5t. �;=Kton, CA 95202-3029 <br /> PERMIT/SERVICES Telephone: (209) 468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATI N <br /> APPLICANT: Oro ` �, I BUSINESS/AGENCY: Lt <br /> Aaya GK t <br /> ADDRESS:/�� f/`� s3 CITY/STATE/ZIP: <br /> PHONE(1): *-5_ 10--5 a PHONE (2): FACSIMILE��9�J <br /> T TATIVE'APPOINTMENT DATE- Time; 7� r <br /> (Please allow 10 busine03 days f to of application cubm I RTonf3fivo only-muet be confirmed) <br /> Cl CHECK BOX TO EXPEDITE REQUES - C O C NLY)-REQUEST PROCESSED IN 3 IRLISIN SS D S <br /> SIGNATURE OF APPLICANT DATP < <br /> Electronic Information: ❑List❑ ap-Description: <br /> FILE ADDRESS EHD USE ONLY <br /> Street>x Street Na e J City <br /> Unit 1 <br /> —..,.._ <br /> -3. t - <br /> - -- -- - <br /> 4 O " <br /> h-Q� <br /> 5. ( I �j <br /> 6. <br /> 7. - (� , <br /> + <br /> ❑unit <br /> 10. V ` t nit <br /> Specific Date Range of Information Requested: From <br /> - - —-- to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE CLOP) ❑HOUSING ABATEMENT OLID WASTE FACILITYIVEHI'KbC <br /> THER CLEANUP SITE(NON-LOP) ❑FOOD FACILITY ASTE TIRE <br /> NDERCROUNDTANK(MONIToRINCIREMOVAL) ❑Doc KGNNGL IRY <br /> HAZARDOUS WASTE GENERATOR ❑CHICKEN RANCH ❑WASTEWATER TREATMENT PLANT <br /> IERED PERMITTED FACILITY ❑MOTELIHOTEL DUMPER TRuCKIYARDICHEMICAL TOILETS <br /> TATTOO/BODY PIERCING ❑POOLISPA LAND Uee APPLICATION SITED <br /> ❑ MEDICAL WASTE FACILITY ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PEkMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> 1. List up to ten addresM In the space above. Select the type(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)464-0138 or mail_0 tho addrass indicated above. Address <br /> ranges will not be accepted-for additional asaietance with filo addrosoen,contact the EHD. AppHoatlonc reaeived after <br /> 3:00 pm will be processed the next business day. <br /> 2. The EHD will notify the applicant if any EHD files exist. 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 fivv businvisis days fvr 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 new application may be <br /> 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 of the applicant. <br /> Future file reviews by the s me applicant may require a$122 deposit prior to review. <br /> EHD USE ONLY <br /> AA-,ate 0+Ct,%h4r4ci nv s, <br /> 1Cy <br /> i aCKI Pw <br /> EHO 40-06 07129170 <br />