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08/28/2003 15:05 209-579-2225 MODESTO ATC } rRuc u, <br /> FHD LOG NUM13E <br /> OAT RfiGEIVEfl SAN JOA IT)EN CONY U <br /> D � <br /> In) 11 [G_,0 Er>vn�orrn�N SAL HEALTa DEPART v> NT <br /> 304E Weber Ave 3"d Floor Stocfston;CA 95205 <br /> AUG 2 8I um.ca.us/ehd <br /> 458-3420 Fsx: (209) 454-013$ Web:www.ca.sau joac�, <br /> ENVIRONMENT HEALTH PCJBL1C RECORDS RELEASE APPLICATION <br /> PERP�11TI5 �1��5 <br /> APPLICANT: BUSINESSIAGENCY: k <br /> ADDRESS: yy--tt It <br /> G�-'xtsVi FACSIMILE: <br /> PHONE: ±1 �, <br /> TENTATNE'APPOINTMENT DATE:, -�f ' -"Time: <br /> (Please allow 10 business days from date of appllcaUon Submittal) <br /> N <br /> CHECK BOX TO EXPEDITE REQUEST-S .00 FEE- EST PROCESSED I .3 BUSINESS DAYS <br /> i DATE <br /> SIGNATURE OF APPLICANT <br /> �.� Department Use Only <br /> I3 I UNrr <br /> 4 Fil E ADDRESS } <br /> p Unit 1 <br /> sveee u ]i , ] Unit 2 <br /> A. SIredd t 3G <br /> a <br /> e. Stl <br /> Unit 4 <br /> Ct <br /> 7. Sul I L <br /> Unit 5 <br /> a. StreN 4 <br /> Ir i� <br /> ta. atroet <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 14 �—��NDERGROUND TANK(UST)CLEANUP SITE(LOP) E3 HOUSING ABATEMENT ❑ SOLI}WASTE FACILITYrS�OTHER CLEANUP SITE(NON-LOP) 13FOOD FACILITY :t O SOLID WASTE VEHICLE <br /> 1CY13NDERGROU ND TANK(M ONtTORINGIREM OVAL) CI DOG KENNET. G1 DAIRY <br /> 1? HAZARDOUS WASTE GENERATOR IO CHICKEN RANCH � ❑ �� <br /> PUMPER TRUCKFY RICHE <br /> ❑ TIERED PERMITTEp FACILITY 13 MOTELlHOTEL +', ;' <br /> C1 TATTOOIBODY PIERCING C3 LAND USE APPLICATION SITES <br /> C2 POOLJSPA i 4 <br /> ❑ MEDICAL WASTE FACILITYDTHER(PLEASE 3PSCIFY} <br /> 1. List up to ten addresses In the space above. Select the types)cf files fromthe s c eckln <br /> the appropriate box(es), At least one file type MUST be selected. F 09 464-0131-or mall to <br /> tb <br /> address Indlcat ve. <br /> 2. EHD will notify the applicant If any EHD files exist. An appointlttint for review will be confirmed <br /> 2pprox1mately five business days but no Inter than ten(10) days sitar receipt of application. The filo! <br /> will be held for a maximum of five business days for review. Appointments should be scheduled <br /> accordingly. F <br /> 3. A file that is actively being worked on by Eli staff may not be linmediately available for review. A ni <br /> appllcation may be submitted when the flis Is available. <br /> !r 4. Any file not returned In the same condition as released will be rdorglsn€zed by EHD staff at the expen: <br /> of the applicant. Future file revlews by the same app It may;`require a$93.00 deposit prior to revle <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff- <br /> 6. Applications received after 3:00 pm will be processed the next b�usinl day. <br /> CONFIRMED APPOINTMItNT GATE }iT1ME t <br /> DATE CONFIRMED y PHON>: . FAX p `aNIT1ALS::. --_ <br /> REVIEWED YES NO REVIEVY DATE <br /> WD45i _ <br /> Midi — <br />