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06/10/2029 11:29 0000000000 PAGE 01/01 <br /> D — <br /> 0CMU LU"IVUIVIOCIN <br /> nE( !1SAN JQAQUIN LQUN7 ' <br /> l <br /> ENVIRONMENTALHEALTH DEPARTM7ENT <br /> JUN 1 Q 2009 304 East'IVeber Aven>re,3 -=t on,Cts 95202-270 <br /> Telephone: (209)469-3420 Fax Web:www.sjgov•olrg/e d <br /> ENVi ,UfVi/tip !i'ES HPER PUSLII;': CORDS RELEASE APPLICATION <br /> APPLICANT: q{1 -BUSINESS/AGENCY: <br /> ADDRESS: 1� ° �7 <br /> PHONE{1): i "1 6 PHONE(2): 416x,- S-(� �=- FACSIMILE:cod 16 ,'6111 <br /> TENTATIVE*APPOINTMENT DATE: TZg1rj&Q T QApwpl� Time: <br /> (Ploase allow 10 businesm days from date of application submittal�"Tentative only-must be confirmed) <br /> ❑ CHECK BOX TO EXPEDITE REQUII*ST-$83.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT --Q!;M MS' 7_ DATE G"IC"a-0!j <br /> UNIT DISTRIBUTION— 1:1 Unit 1 'D Unit 2 0 Unit 3 a Unit 4 CI Unit 5 © Unit 6 0 Other(electronlcllistsfmaps) <br /> FILL ADDRESS EHD USE ONLY <br /> Streot 0 _ Streel:Name2. <br /> Gity <br /> 3. <br /> 4. <br /> 6. <br /> 7. <br /> 8. <br /> 9. <br /> 10. <br /> Specific Date Range of Information Re;iluested: From to T <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> �h <br /> ©UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑HOUSING ABATEMENT 10 SOLID WASTE FACILITY/VEHICLE <br /> ❑OTHER CLEANUP SITE(NON-LOP) a FOOD FACILITY 0 WAST£TIRE <br /> O UNDERGROUND TANK(MONITORINGIREMOVAI)V, El DOG KENNEL V DAIRY <br /> ©HAZARDOUS WASTE GaENERATORC)( ®CHICKEN RANCH 0 WASTEWATER TREATMENT PLANT <br /> D TIERED PERMITTED FACILIT)(]( <br /> ©MOTELIHOTEL 0 PumpaR TRUCKIYARPICHEM TOILETS <br /> O TATTOOIBODY PIERCING V 0 POOLISPA 0 LAND USE ApI!LIGATION ITES <br /> *MEDICAL WASTE FACILITY ®OTHER(PLEASE SPECIFY) .xAlf �IL'tt~�+1Qmr, s��mm t R <br /> WELL AND SEPTIC PERMIT REGORUIS ARE AVAILABLE FOR REVIEW- MONDAY-FRIDAY 8:00 AM-5:00PM - BXCLUDING HOLIDAYS. <br /> 1. List up to ten addresses in the aI pace above. Select thetype(s)of files from the list above by checking the <br /> appropriate box(es). At least ope file type MUST be selected. Fax to(209)464-0138 or mall to the address <br /> indicated above. Address rancl.as will not be accepted—for additional assistance with file addresses,contact <br /> the EHD.Applications received .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 review will be confirmed <br /> approximately ten (10)days aftlor receipt of application. The files will be held for a maximum of five business, <br /> days for review, Appointments should be scheduled accordingly. <br /> 3. A file that is actively being worked on by END staff may not be Immediately available for review. A new <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 expense of the <br /> applicant. Future file reviews by the same applicant may require a$93.00 deposit prior to review, <br /> a" � .,,I <br /> Cud 4-0 Ate T <br /> EHD 4002-000 --�� <br /> 11/23/04 <br />