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11 / 10 / 2003 16 : 20 209 -579-2225 MODESTO ATC - PAGE 01 - <br /> D -� rrm <br /> 11 SAN JOAQUIN COUNTYPUBLIC HEALTH SERVICES <br /> NOV 1 0 2003 ENVIRONMENTAL HEALTH DIVISION <br /> E 'LNVRUNMENT HEALTH 304 EAST WEBER AVENUE, THIRD FLOOR <br /> PERfl41T/SERVICES sTOCICTON CA 95202 <br /> (209) 468-3420 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> I APPLICANT f riI Qi /" \` i BUSINES5IAGENCY <br /> ADDRE55 <br /> PHONE Sn- 7.2-21 FACSIMIL//�"�� ZdZ $ ^ 'L 2Z <br /> TENTATIVE" APPOINTMENT DATETIME <br /> (PIC�SC give 7 la i0 buainoaa u,ys from [I�IC of spl�lieulion au�+nillal) <br /> CHECK aOX TO,GXPEDITE RCQUE5T • 507.00 FEE, I1RCOpUL�S�T PROCESSED IN 7 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE _ It AS ^ <br /> FILE ADDRESS - THIS SIDE EHD sTAFF USE ONLY <br /> PROGRAM ELEMENTS SEARCH <br /> QZ � L` • t ' �� S�ti'-1� <br /> - <br /> t' HA ���. t ♦ Icy S�Ck <br /> Z Et 3• rs41 A s 'txr` Fry LM Ce. U-10 <br /> 5'} i5t po,r.�la Sit•-+k Sko �.K4o-+ � <br /> � 1 5 , I <br /> Der.d4 5 � ocvKko3 •. <br /> � L t.n.1t k1o � �• <br /> •ot1 t,...) 1 ;GK n <br /> a <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> b{ UNOeRGROUND TANK (UST) CLEANUP SITE ILOP) ❑ HOUSING ADATEMflNT ❑ SOLID WA5TE FACILITY <br /> ❑ OTHER CLEANUP SITE (NON •LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> ❑ UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELMOTEL ❑ PUMPER TRUCK)YARD/CHEM TOILETS <br /> ❑ TATTOOIUODY P14IRCING ❑ POOi ❑ LAND USE APPLICATION SnYS <br /> ❑ MEDICAL VVASYii FACILITY ❑ PUBLIC WATER SYSTEM ❑ OTHER (PLEASE SPECIFY ADOVE) <br /> 1 . List up to, ten addresses in the space above. Select the types) of files from the list above by chocking <br /> the apprpriatc box((! s) . At ( cast one file type MUST be 51 Fax jo 209 464-0130 or mail to the <br /> address indicated above . <br /> 2• CHD 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 ton (10) days after receipt of application. The files <br /> will be held for a maximum of five business days for review. Appointments should ba scheduled <br /> accordingly. <br /> 3 - A file that is actively being worked on by EHD staff may not be immediately available for review. A now <br /> application may be submitted when tha file is available. <br /> 4 . Any file not rcturned , in the same condition as ratcasad will be riper by EHD staff at the expense <br /> Of the applicant, Future file reviews by the same applicant may require a $ 07.00 deposit prior to review. <br /> 5 • "TENTATIVE appointment dates must be confirm❑d with EHD staff. <br /> 6 . Applications received after 3 ; 00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE <br /> FAX INITIALS <br /> REVIEWED YES NO <br /> REVInW nnTF <br />