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w•��r�w �� ZMr4U�h{7Wlik3i . <br /> SA'WQAQUIN CO[ NTYPUBLIC'MEALTH S; JCFS <br /> ENVIRONmeNTAL Hr:ALT.H DIVISION <br /> 304 FAST WEaE R AVFNUF,THIRD FLOOR / G <br /> ST==TON CA 95202 C�/ •J <br /> -(2a9)408,1420 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> map <br /> APPOCANT R1—t— f- Vs 13iiSIlVES51AG£1+t�7 . 4Nbo aLog?tG <br /> A01DR✓SS til- W15,S-T GP44A-t Sidw _.L.., S,TISU�tbN� Z-o_G _ <br /> Tt`rv-raTivi�APPb1NTly1>=NT�DA7E",• _ t�E �,- <br /> (Pla>zaa Diva 7 to 10 bvwinaaa days trans dada of a9p4ceGan subr>YillW) <br /> C"kt!KBox Tfl --REQUeSTPR0QES:i!0H13tW5W?-13$CAvs <br /> SIGNATURE-OF APP1_rANT DATE o �oj <br /> FI ADDRESS TtifSSIAE E56t-TAFF Use ONLY <br /> PRQGItJLM PLEME14TS XiEmcw <br /> ENVIRONMENTAL HEALTH DiV;SICN F14ES <br /> SSC QN0VFtGR011N0 TANK&3n CI.t=ANUP WA(LCV) o »O hio aUATEM NT k soUQ VYASYe FAULITY <br /> Ot' OTHER CLEANUP*tTl:(NON-LOP) root)EACILtry L1 SOLID WASTP VEWLE <br /> &Z VNQERGROUNGTANK MIONITORWWFW i)VA4 0 AOG KENNI"L )m 0MRY <br /> LSC HAzmtOpUS wA&TF-6EhtteRAToR JZ CHICKEN RANCH Ci PKG T1F1,C/1TMENr PLANT <br /> C7 TIERED PEIRMIT=AD FACILM Q MaTeLn OTEL a a}UWIEtt 3 RIJGWYAFt�CHEFA19�ETS.: <br /> C] TAYYO016MY PEe4MU 0 ROOLJSP!A: Cl LANE)QSE APPLICATICH U S <br /> t MEE11CAsL WASTE FACILITY Q PUBLIC WATER SYSTEM. 19 OTIRA(!'LEASE 3PEOFYASOVE) <br /> 1. List up to ten addrxsses In the space above. Select the type(a)of flies from ttte list abcvQ by Cbei;Wno <br /> the appropriate box(es). At least vriv file type MYST Ile SRlactad. Fax to TIS$ 46"131 Qr mail Whq, <br /> 2. FrH13 will notify the applicant if any EMU files 0XIsL An appointment for rgvlew vel li by 4=tdirmcd <br /> approximately five bv*lness days but no later than ten(1E))days after receipt of appiksat-ton. Yho files' <br /> Will be bald 19r A maximum of five buainees days for review. A,ppolnUnents should be ac bc(taied <br /> aat:ordillgly. ' <br /> 3, A tits that la activaij veins worked on lay F-HD elaff may not be Irnmediateiy 4viliilable for review_ A rrew <br /> appilnation may ne Suamltted when the Elle is available. <br /> 4. Any file riot retura&O irh tihe same condition as Mleaaed wlii be reofaanaed by EIAD staff'at the expense <br /> Of tilt APPlica"t. Future file r'evlews by the Same applicant maty mqulte a$117.00 tl8pos_ it prior to refriaw. " <br /> 5. *TENTATIVE appointment dates must be confirrnad wifth EHl}staff. <br /> 6. Applicatlons recol ed atter 1.00 Pin will tiJ--pzOCcssed the next business stay. <br /> CQNPIRMEU APPOINTMEkT DA'YE TIME <br /> VATI"CONFIRUI D P}it7RE FAX 1NJTIAL6 <br /> RrEVI£vim YES NO R£VIFW DAVE - <br /> sra sewn <br /> TOTRL P.02 <br />