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04/11/2003 08:29 209-579--29-25 MODESTO ATC PAGE 01 1 <br /> Fr <br /> n. .-� AN JOAQUIN COUNTYPUBLIC HEALTH 5E 'JI+")= <br /> ApR t 0 2003 ENVIRONMENTAL. HEALTH DlViS10N' <br /> 304 EAST WESER AVENUE,THIRD FLOOR; <br /> J'=.Iti+..:NI�'1l:kVT HEALTH (20 S7 TON CA 952 <br /> 02 s <br /> �. ��UI��S (z09) 468-3420 1 I <br /> PUBLIC RECORDS RELEASE APPLICATION I <br /> �( � I <br /> APPL(CANT 0U51NESSfAGGNCY__. ~� <br /> ADDRESS <br /> PHONE Z�� S• Z-•ZZ LCa� _ h <br /> FACSIMILE ���5� <br /> I TENTATIVE"APPOINTMaNT OATH 0.1 74-cl-5TIME: <br /> (Plcasp Diva Y ttl 10 buwna9� s dayIlb,n date ry ti <br /> of applical q .ulomlta) I-0-3 <br /> Q hII Luis <br /> CHt:cK 13OX TO. X( CDITF_RIZOVEST-$07.00 FEE,_REQUC5TPROCESSF IN 1 13USINC55 Ofi <br /> SIGNATURE OF APPLICANT .Curr V oma. I I <br /> ' I _ DATE `7 '11(`03 <br /> - <br /> FILE ADDR>_S,5 �I <br /> a <br /> J. His Slur.EliD STAFF USE'ONLY <br /> :I•PROGRAM ELLMEKTS SEARCH <br /> a g ro� �,, z o10 <br /> z S I 4 ,• �.,r <br /> C C.0,t4 �v�[�I..i. ��Cat nn - <br /> 'a (Vd <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> )4 UhOPRGrtOtfNp TANK(U577 GL>~gNUP S[TC(LOP) <br /> CI ❑ HOUSING gpATEMENT ❑ <br /> l OTHER CLEANUP 517E(NON•LOp <br /> � ❑ FOOD FACILITY � SOLrD WASTE FACILITY <br /> CMOVAL) t7 DOG KENNEL rf C7 SOLIn WASTE YI:I41CLE <br /> ❑ UNDEFLGROUNb TANK(I410NiTC1Rl1`tG!}3 <br /> O HAZARDOUS WASTE G1:1412RATOR17 OAIpY <br /> ❑ TIEFteo PERMITTKD FACILiTr 17 CHICKEN RANCH f C7 PKG TREATMECN'r PLAN?• <br /> d TATTO0130DY PdifiCING ❑ MOTEUHt)TI;L ❑ PUMPIER TRUCKWARDICHEM TOILETS <br /> ❑ MEDICAL WAS'(d FACILITY 0 POOUSPA f p LANG USE APPLICATION SITES <br /> O PUQUC WATER SYS-TEM 1107HER(PLEASE 4PECIFY ADOVEI <br /> �• List up tv ten addreSSUS in the space above. Select the type( <br /> s ti(filr.5 from the lis;above by checking <br /> i <br /> the apprc�priatC box(esJ, At least one fila type MUST be 5010cted' Fax to 120 aG4.()13t3 Qr mail to the <br /> addrr!55'irl icalcd above. ,i k <br /> z. EHD will notify the applicant if any EHD files exist. An appointmont for'favirtiv will l)r, Confirmed <br /> 'I approximately five business days but no (atCr than ten (10) daysf[w rc0c.lpt of afi�riicatrvn. TI c files <br /> + will be held for a rnaxil�tum of five business days for review. Appointments shatlfd be scheduled <br /> aCCordlnr3)y. C <br /> 3 A file that is act)vely bein fj worked on by EHD staff may not br irrlinadiai�el +vaillblr. r <br /> appllCatlon may bu submitted when the filo is avallabio. y fill rovievr. A now <br /> 4. Any file not roturnetl in tt7c same Condition as released wIII be r0rijanized by EHO ;;teff at tlSc o:tpcnac <br /> of the al?plicant. Futuro file reviews by the same applicant may ro.quire a 507,00 deposit prior to rcvir:tinr. <br /> 5 *TENTATIVE appointment dates must aac Confirmed with EHD stat#. <br /> 6. Applications received after 3:00 pm will be processed the next business'�day. <br /> I <br /> CONFIRMED APP <br /> OIIVTMNT DATE <br /> TIME ?� ` <br /> DATE CONFIRMED <br /> PHONE FAX �# <br /> REVIEWED INiTIALs �r <br /> �� ua a aua roe <br /> YES NO REVIEW DATE'l <br />