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07 / 30% 2003 11 : 30 209- 579 - -?5 MODESTO ATC PAGE 01 <br /> i� EHO LOG NUMBER <br />'pppl BATEREGEIVEO , A <br /> SAN JOQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT `O <br /> J U L 3 0 2003 304 EAST WEBER AVENUE, THIRD FLOOR <br /> STOCKTON CA 95202 <br /> (209) 468-3420 <br /> " it <br /> ` U I' PUBLIC RECORDS RELEASE APPLICATION <br /> 1 �' BUSINESSIAGENCY ATC <br /> KO+ <br /> APPLICANT JI Ver I <br /> ADDRESS <br /> IF Lame P , lu <br /> 2� _ cV TZz1 ( FACSIMILE <br /> PHONE <br /> 1, 7K,tlZ TIME <br /> TENTATIVE' APPowTMENTgive tk A Irl <br /> (Please glue 7 to 1 D bNslness days from date o1 application submittal) 2 J( <br /> ❑ CHECK BOX TO EXPEDITE REQUEST 1111139. 0 FEE - REQUEST PROCESSED IN 3 BUSINESS DAI <br /> _ DATE w l <br /> SIGNATURE OF APPLICANTIII ME <br /> THIS SIDE EHD) STAFF USE ONLY <br /> FILE ADDRESS PROGRAM ELEMENTS S CH <br /> Zo t. v sefk Foy <br /> ( EIcI N 5+b <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT SOLID WASTE 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 ❑ MOTELIHOTEL ❑ PUMPER TRUCKNARDICHEM TOILETS <br /> ❑ TATTOO[BODY PEIRCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECIFY) <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 ( 2091 4644138 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 files <br /> will be held for a maximum of five business days for review. Appointments should he 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 /> of the applicant. Future file reviews by the same applicant may require a $ 89 .00 deposit prior to review. <br /> 5. `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 /> IF I <br /> CONFIRMEDAPPOINTMENT DATE�1. <br /> . TIME _ <br /> III IF I <br /> FI I <br /> DATE CONFIRMED : PHONE FAX INITIALS 4 IF <br /> IF <br /> I IF <br /> REVIEWED YES NO REVIEW DATE <br /> EHD Ud2aoe <br /> anw2aoo <br />