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U9/I71/2PJb4 12:4( . . 2091-579-2225 MODESTO ATC PAGE 111. <br /> DATE RECEIVED • EHD LOG NUMBE <br /> 1, � . SAN JOAQUIN COUNTY <br /> I t§EIJ EiNVIRONMG,'NTALHEAL.THDEPA,RTMXNT <br /> 304 E Weber Ave 3`d Floor Stockton, CA 95205 <br /> I� �r <br /> SEP 0 1 2004 (209) 468-3420 Fax: (209)464-0138 Web:www-co.san-joaququin.ca.us/ehd 7 <br /> LiN& IMENT HEALTHpL1BLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: Of`e.W V ck, Mt- BUSINESSIAGENCY: AT C' <br /> ADDRESS: ff" L,3,&P- PQ�'V� S.tt 13Mo�Sb <br /> PHONE: S-+Jl - Z,'Z'LI FACSIMIL�:I �'°1 5, <br /> TENTATIVE*APPOINTMENT DATE: I L�ALi 'nm•: () � <br /> (Plan"allow 10 business dwA from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93'00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT L"-�L P�1- DATE 9 12'4 <br /> J)O • or�'� La� Qty r Si S (l�raJM L� 1U5frQCd�j � Dspar"ntUse Only <br /> 3355�'4p�rn z1�e... 9aaavnMe.«, 5SL`Vo(s4lt�I� k�4.Oct�.Ch♦l\0,CL.+L� SFIL5ADDRfrADDRESS <br /> ESS da SS SS�Lcavt k H�''yi 2 •�I <br /> UNIT <br /> /AKo{0UC] Unit 1� <br /> 3. C. �M 'l y Unit 2 <br /> t-% cL e- <br /> �•�///Q Q Cl <br /> Sl� <br /> 3 <br /> r. 3 W. Ck�r r a S�-ot.eClon Un <br /> 3sa� d S Ck <br /> Safi r' `e. ev,.� '�Z3.n N, lTilS1- q� <br /> 3537 Z' CK ❑ Unit 5 <br /> 3 5a� <br /> o. sv.x 1 Si tJ'JY cve. ^� m, 5 e. <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> t2 OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> W UNDERGROUND TANK(MONITORINGlREMOVAL) O DOG KENNEL ❑ DAIRY <br /> ISI HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> Id TIERED PERMITTED FACILITY C3MOTEVHOTEL C3 PUMPER TRUCKIYARDICHEM TO <br /> ❑ TATTOO/BODY PIERCING in POOL/SPA ❑ 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(s)of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mall to ttlfl <br /> address Indicated ab9vo. <br /> 2. EHD will notify the applicant If any EHD Tiles 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 net <br /> application may be submitted when the fila Is avellable. <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 Sams applicant may require a$93.00 deposit prior to reviev <br /> S. *TENTATIVE appointment dates must be confirmed with END staff. <br /> 6. Applications received after 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRIMED PHONE FAX ' INf fIALB . <br /> REVIEWED YES NO REVIEW DATE <br /> vw <br /> uvxaw . <br />