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05/03/2006 11:34 209-579-9=q MODESTO ATC PAGE 02 <br /> DATE RECEIVED 1;7��1 AN qQAQe.R g� I�.UI?�fNT"Y EHC1 LOG NUMBER <br /> ENVIRONMENTAL.HEALTH DEPARTMENT 40 ,Oft <br /> 304 But Weber Avenue,3r4 Floor,Stockton,CA 95202-270$ -35 <br /> Telephone;(209)468-3420 Fax;(209)464-0138 Web:www.sjgay.org/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: „ BUSINEs9/AGENCY:AmO A .•j ""f` <br /> PHONE(1): ,, 22'x..1 PHONE M: FACSIMILE: ?�I• ' • aL "? <br /> TENTATIVE"APPOINTMENT DATE: 5 171•g Tame: -� - <br /> (Please allow 10 business days from date of application submittal-*Twnlefm only-must be conium d) <br /> d CHECK BOX TO EXPE E 193.00 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 SV3INP36 DAY$ <br /> SIGNATURE OF APPLICANTDATE f�-Z <br /> UNIT DISTRIBUTION 0 unit 1 0 unit 2 066UnK3 OCWN4 0 Unit 5 thtit S 0 Other(eleclxonlc/Qr ) <br /> FILE ADDRESS EHO USE ONLY r <br /> 8tre Street Nome City s y <br /> CAfefi:m a- '06�\ 2. 1 <br /> 4. <br /> �. t ga <br /> 6. <br /> 7. <br /> 8. <br /> 9. <br /> Speeffic Date R arge of Information Requested:From $'r" to e <br /> ENVIRONMENTAL HEALTH DEPA ENT FILES <br /> UN0ER®(WINo TAmK(U9T)CLEANUP 8 rE(LOP) 0 HOusm ABATEmarr ItSwD WASTE FAcurYNEHICLE <br /> OnCk CLEANUP SITE(N004LOP) M F000 FACILITY 0 WASTE TIRE <br /> ,IQ TAw(motar(xttN i(R£mwAL) 0 DOG KENNEL 0 DAIRY <br /> VR3 HAZARDOUS WASTE GONERATOR 0 CHICKRN RANCH C3 WASTEWAUR TREATMENT'PLANT <br /> 1BTRRWPERWMDFACUTY D MOTEWWOTEL D PUMPER TRUCKYARWCHEMTOILETS <br /> 17 TATTODIBODY PIEROM D POOLlSPA 0 LANs USE APPuCATIoN SITES <br /> 1B MEDICAL WAM FACILITY 0 OTHER(PLEASE.9PECWT) <br /> WELL AND SEPTI POWT RECORDS ARE AVAILABLE FOR REVIEW-MONDAY-PRMAY 6:00 Am-MOOM . EXCLUMNG MMMArs. <br /> 1. List up to ten addresses in the space above. SeW the type(s)of files from the:list above by checking the <br /> appropriate box(es). At least one file type MUST be selected. Fax to(200,)484-0138 or mail to the address <br /> indicated above. Address ranges 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 tw confirmed <br /> approximately ten(10)days after receipt of application, The flies will be held for a maximum of five business <br /> days for review. Appointments should be scheduled accordingly. <br /> 3. A file that is setivoly being worked on by EHD 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 /> EHa saossa <br /> 1174AQa <br />