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J`'Atr JC L{iV I.l•U lil/IVL•LJ. <br /> tUIN COUN-rYPUBLIC HEALTH SL_i/ICE�S <br /> =Nb'lRONMENT•AL HF-ALT[-I DIVISION Q <br /> 1104 CAST WEBER.AYEt4UE,Tl-3IR0 FLOOR O <br /> S'rOCKTON CA 95202 <br /> (209) 4613-342-0 <br /> PU8L'IC RECORDS RELEASE APPLIGATION <br /> APPLfCAAi'r TFU <br /> SUZU LSSIAGENCY F Iy' SA 1 i ajyT`'1 s <br /> .AUPRESS (D l - <br /> �Horr� FACaiACLE� S-- <br /> TENTA-riVE'APP41N7MEc14T'DATE J �t TIM OJ) Y-n-C, <br /> (P;ca3B OfWc 7 fa'IQ)? ,mess days ft.date orappGcalfon Suprtrletal) <br /> CiI1=GK 80X To E7CPElarrE ROUESTDO <br /> FFA-REQ ST PROC888FD IN J 8VSINESS DAYS <br /> SIGNATURE OF APPLICANTDATEIVA&Am <br /> r� <br /> Fif ADREZESSF_ - <br /> • <br /> 17-iIS SIDE EHb STgFF US&ONL <br /> I <br /> PRQGRAM LLMMENTS SEARCH <br /> V <br /> .a <br /> ENVIRONMENTAL HEALTH DIVISION FII_ES <br /> VNpEKGROUNV TMIK(UST) CLEANUb SiTF(LOP) Ct HQUSIDIG P13ATEMEXT SOLID WASTE FACILITY <br /> OTHER CLEANUP 15117-4 0011-LOP) Q FO00 VAMLITY SUUD WASTE VEHICLL- <br /> UNDERGROUND TAT12t(taON[TQRIKGIC.BPiDVAI�I ❑ pQG KENHf ❑ DAIRY <br /> K�DQUEWASTE GF-NERATOR Q CHICISLNRANCJi d PKGTREA7iaENTPLAItT <br /> TIERED VBO D 1TrE( FACILITY Q MO T ELMOTEL a PUMPER TRUCKfYA ZDICHEIIF TOILETS <br /> ❑.7AZI0016aDYPE[RC[MG ❑ I.00jaPA ❑ LANDU56ArPLiCATi0NSITES <br /> Q YvasTE FACILITY 0 PUBLIC WAFERSYSTP-M ❑ OTHER(PL"SF_VPE-CIFYAB0VJE) <br /> List up to ten adCresses,n the spaco above. SClJ3et the types) alfcfas frem the IIsi above by checking <br /> ille appropriate box(¢s�_'At least one fife type MUST ba selected. Fax tc, (z09} d6G-0736 or mai[to[frrz <br /> L-irfdtcatecl above! <br /> 2 EHO will notify the applicant If any EHO files exist. An appointment for review will be canFirmnd w <br /> aPPr>,ximately five bush ess flays 6u;nO later than ten f10) days after receipt of application,-The files <br /> Will bE held for a maximyrn of five bUsinoss days for revlerr. Appoin4nonts sheuid be scheciulecS <br /> accorduzgiy, <br /> 3 A fila that iu activaly baro. Work= on by EMD staff may not bu irnmcd[ately availabla far rev,IeW, <br /> application may b�subrrifttetl When the file is cvallable, A new <br /> • Any Elle czor returned!n t�c same conditlan as released will be rerrganiaed by EHO staff atthc expense <br /> Of t.`)e applicant Future file review-5 by rite same applicant May requiro a$87.00 deposit poor to review. <br /> 5 `TENTATIVE apgvintrnent dates mu5t be canfinned with EHO staff_ <br /> �• Applicaj cQns received after 3:q0 pM will be processed the next business day. <br /> r _ <br /> 1 <br /> QQNFIRMED APPOINTMENT DATE <br /> I TIME <br /> a <br /> ATE-CONFIRMED PHONE <br /> FAX 1NITIALs <br /> IRR;VIE,WED YES NO ----.�-- <br /> ++vQ t rco REVIEW DATE _ <br /> TOTAL P.01 <br />