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e'J/UI/2171J4 12:4/ . 2U9-5/9-2225 MODESTO ATC PAGE d1 <br /> DATE RECEIVED EHO LOG NUMBE <br /> r I i;�;� SAN JOAQUIN COUN'T'Y <br /> D ENVLRONIIT..;~,N'>('AL 113EALM DEPA-RTIYMNT <br /> SEP 0 1 2004 304 E Weber Ave 3"1 Floor Stockton, CA 95205 <br /> {209) 468-3420 Fax: (209)464-0138 Web:www.co.san-joaquin.ca.us/ehd <br /> dVfi,A11"v ENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: V f"(-W Q o` % 0'`'^ BUSINESS/AGENCY: AT Q_ <br /> ADDRESS: tW+ L%31&'L Pates L�LAI D. I�'loe�slo <br /> PHONE: S1­� - ZZ''i FACSIMIL . S 7-9 - zL7-r G <br /> TENTATIVE*APPOINTMENT DATE: -I I Time: C) I Q <br /> (Please allow 10 business days from date of application submittal) <br /> El CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT D v -Pik DATE <br /> (D,�l_y L<>t R14s r S s +#-04-As �"N l� tA5 IL reQ,, "t Deoarment Use Only <br /> FILE ADDRESS UNIT <br /> R!XslQ!2-L iiA' <br /> z street 51 SI CkL AC w.rt cx S cac H - ­­­7 <br /> — C7 Unit 1 <br /> 3 S.) s�.e< C� Q�y << ucaZ. Y ­+' S [� Unft2 <br /> 35024 nig •. street � �nt� l,e tA� T L� .'+' h i Z <br /> tQkCO3,\ aty <br /> 3 5 7 U e, street <br /> 1144 r t,,AlL\ (h d , d /,kr3 t_ti <br /> a 5�.c LV Un. <br /> -3 5 a�r' `�e. �S .a �Z 3.ra 1\t, l>,1(14- to+�-L S t k• <br /> 351)-7, 242;1_` �t q ❑ Unit 5 <br /> 5,;0t). street 1 5►t,vq"' cV 4 a1 Cu `a 0" <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> 12 OTHER CLEANUP SiTE(NON-LOP) 0 FOOD FACILITY C] SOLID WASTE VEHICLE <br /> Its UNDERGROUND TANK(MONITORINGiREMOVAL) ❑ DOG KENNEL O DAIRY <br /> hr HAZARDOUS WASTE GENERATOR C CHICKEN RANCH O PKG TREATMENT PLANT <br /> 17 TiERED PERMITTED FAC1Lrr-Y C7 MOTEUHOTEL ❑ PUMPER TRUCKIYARD/CHEM TOILETS <br /> TATTOOBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> 1. List up to ton addresses in the space above. Select the type(q)of files from the Ilat above by checkinG <br /> the appropriate box(es). At least one file type MUST be selected. Fax to 2)464-0138 or mall to SU <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 be scheduled <br /> accordingly. <br /> 3. A file that Is actively being worked on by EHD staff may not be Immediately available for review. A nev <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 expens, <br /> of the applicant. Future file reviews by the same applicant may require a$93.00 deposit prior to reviev <br /> 5. *TENTATIVE appointment dates must be confirmed with EHD staff, <br /> B. Applications received after 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX :':IN&ALS. <br /> REVIEWED .- YES NO REVIEW DATE <br /> Awa-0w r <br /> AnV20" <br />