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04/24/2006 10:05 _ 209-5795 MODESTO ATC PAGE 02 <br /> EHG,LOC NUMBER <br /> SAN JaAQvnv COUNTY <br /> ENVIRONMENTAL HEALTIi DEPARTMENT <br /> 2066 304 iEast Weber Avenue,3rd floor,StocIcton, A 95202-2708 <br /> Telephone:(209)468-3420 Pax:(209)464-0138 Web-,www s 80v org/eh6 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES pUBLYC RECORDS RELEASE APPLICATION <br /> APPuCANT:A) <br /> BUSINESSIAGENCY: ���• <br /> ADDRESS: °► <br /> PHONE(1): PHONE(2): FACS3tAA{LE: �� <br /> TENTATIVE*APPAINWENT DATE: Tlm°:�+��►- <br /> (Pieama alloy to business days from Oats of apPlI on submittal-"rant&Mm cnlY-must ba cvnflrmed) <br /> 0 CHI+GY:SOX TO EXPEorrE REQUES -$93.00 FEE(CASH OR CHICK ONLY)-REOUEST PROCESSED IN 3 HUSINF$8 DAYS <br /> SIGNATURE OF APPLICANT r DATE <br /> UNrf OI3TRl5UTlON ❑ Unit 1 ❑ Unit 2 Unto 3 U t ,' ❑Unit s tlnit 6 M(aisctrvn Icllluts!nle") <br /> FILE ADDRESS EHO USE ONLY <br /> g, � 8#raet Name City <br /> i. <br /> 2. ✓ ,,• �� � I <br /> 3. <br /> 4. v$ ' <br /> �► .r <br /> g. <br /> 10. <br /> specific Date Range of Infotsnatlon Requested:From _F SI" tot�— <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> uNDERQR0uND TANK(UST)CLEAHuP SITE(LOP) C7 Houma ABA.TEMmT IQ Sa.m WASTE FArALffY1V'EIMCL1 <br /> t7 OTHER Ca"p arm(NCM-LOP) 0 FOOD FACUTY Cl WASTE TIRE <br /> UNDERMUND TANK(MON90MMUMMOVAL) C3 Dos KENNEL M DAIRY <br /> iAZARDou3 WASTE GENERATOR 0 CKcKEw RANCH O WAsTmmnat TREA,TMErdT PIAr-T <br /> O TiCRED PEND FACILITY a MOTMJHOT€L 0 Pt1WM TffixvYARDICHEM 70-UrFs <br /> ❑TATTOOIBODY PwRcINQ O POOUSPA O LAND USE APFIJCATKM SITE$ <br /> MEU=AL WASTE FACILITY ❑OTHER(PLEASE$PECIFY) <br /> WELL AND SEPTtO PEwArr Recopws ARE AVAK AAI.lr POR REv1Ew - MotcDAY-FinaAY 8:00 AM-i:QOPM - ExCLUDiNa HOUDAya. <br /> 1. List up to ten addresses In the space above. Select the type($)of fines from the list ab*ve by chocking the <br /> appropriate box(es). At least one file type MUST be selected. Fax Ig(202)M4-0133 or mail toAhi-address <br /> Indic4tpdabove. Address ranges will not be accepted—for additional assistance with Tile addreiss ez,contact <br /> the EHD.Applications mcelved after 3:00 pm will be processed the next business day. <br /> 2. The EHD will notify the applicant if any EHD files exist. An appointment for ra view will km confirmed <br /> approximately tan(10)days after receipt of application. The files will be held for a maximum of fivs business <br /> bays for review. Appointments should be scheduled accordingly. <br /> 3. A file that is actively being worked on by EHD staff may not be Immediately avaltable for review. A now <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 expans}a of the <br /> applicant. Future file reviews by the same applicant may require a$93.Q0 deposit prior to review. <br /> 1 <br /> 1 " ' <br /> IND 4842404 <br /> v1�ms <br />