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�H ItNECE1VEQ <br /> #, SAS--JOAQ WN COUN'T'Y EHD LOG NUMBER <br /> r~NVIRONMAL <br /> 600 East MaE S �reet1s oAk#ons, Coq DEPARTMENT <br /> 20 -3029 <br /> Telephone; (209)468-3420 Fax: 209 464-0138 Web2www.s' <br /> )govd <br /> AF'pi.icANr: <br /> PUBLIC_ RECORDS RELEASE APPLICATION,� �� I <br /> ADDRESS: <br /> � I Bus1Nl;SS1ACENcr; Gr:oT( ,rJS <br /> I C. <br /> PHONE(1): ,(0' -7)(DCity/Statelzlp ilr <br /> PHONE(2): � 1 �G�-� 2 -1 <br /> TENTATIVE* ' FACSImji e; ��� 9, ?,_ <br /> ApF01NTMENTDATE: J` v c /8fvCF <br /> f (Please allOW 10 business da Z <br /> ys frp►tl date of appN�atlon submittal-*Tentative oniTime: r1r l-1 <br /> © CHECK BOX 1O EXPEDITE REQUEST-$405 FEE(CASH R ONE K ONLY)-REQUESTy-must be confirmed) <br /> SIGNATURE OF APPLICANT RRaCES$Ep IN 3 BUSINE S$DAYS k <br /> 1. DATE <br /> Electronic Information: ❑ List Map-CJescription: <br /> FILE ADDRESS j <br /> Street <br /> 'I. 44Stroot Name END Fill <br /> QNLY <br /> ��-•2 -. crty <br /> � <br /> 2 ' i c I.0, <br /> . C ---�.�'� 'l��C��2�i�-I 1• 0 UnIt1 <br /> 3 - ' 3f� c ��.lr ILLS-l- / , ❑ Unit <br /> 4. ,CC�� - Ck { �f <br /> 6. <br /> 7. - .. <br /> Unit,4 <br /> 9. d Unit S ; <br /> Unit ti <br /> Specific Date Range of Information Requested:From ` <br /> to C Cz-c=-5��j'• ,� � <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES_ <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT <br /> Rr'pTHER CLEANUP SITE(NON-LOP) ❑FOOD FACILn-Y IMOUD WASTE FACILITYIVEHIcLE <br /> 0'UNVCRGROUNb TANK(MONITORING/REMOVAL) ❑DOG KENNEL 0 WASTE TIRE <br /> 0'11IAZARDOUS WASTE GENERATOR !"I CHICKEN RANCH A DAIRY <br /> Q TIERED PERMITTED FACILITY ❑MOTELINOTEL A WASTEWATER TREATMENT PLANT <br /> ❑TATTOOIBODY PINRCING d PUMPER TRUCKIYARDICHEI4 TOILETS <br /> OTHER(7 <br /> ❑MEDICAL WASTE FACILITY ❑ THER PA(PLEASE SPECIFY) d LAND GSE APPLICATION SITES <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REvicw - MONDAY-FRIDAY 8:00 AM�5:00PM - FxCLUDING HOLIDAYS. <br /> 1. List up to ten addresses in the space above. Select the type(s)of flies from the list above by checking the appropriate <br /> bax(es), At!east one file type MUST be selected. 461 ma the addess io2ndicated bove. Address <br /> ranges will not be accepted—for additional assistance with file addresses,contact the END. Applica{ions received after <br /> 3:00 pm will be processed the next business day. <br /> 2. The END 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 five business days for review. Appointments <br /> should be scheduled accordingly. <br /> 3. A file that Is actively being worked on by EMD 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 some condition as released will be reorganized by EHD staff at the expense of the applicant <br /> Future file reviews by the same applicant may require a$105 deposit prior to raview. <br /> END USE ONLY <br /> i <br /> $FED 48.06 8!04108 <br /> t <br />