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08/04/2029 07:58 000000OP90 PAGE 01/01 <br />DATE RFCPIvED t� <br />_ TOA CrIW I.Vta NUMt31:ht <br />SAN ,j <br />t'�`I QiT[N COUNTY It <br />EN`S IRONMENTAL HEALTH DEPA.TiTmENT <br />304 East Weber Avenue, 3rd tor,., 0195202-27p8 <br />Al l] 7.009 Telephone: (2 D9) 468-3420 ]Fax (209) 464-013 Web: www,sjgov.or <br />ENV!'i �"4 1^;� ; r''J'i ��='a� ti Pu.ryl.PL"... RECORD <br />P6=fir; ';:�:S RELEASE A SE AP��,zC �'zON <br />APPLICANT: )QSrN Mr -r L.P,C �I;j BUSINESS/AGENCY: <br />ADDRESS: C> <br />PHONE (1): _ PHONE (2): _ �G , L-4 6 R __FACsrMILEr Ca �,� I J <br />TTI NTATIV E;* APPOINTMENT DATE: Time: 91, -110 <br />(Please allow 10 buslnevi days from date of application submittal-*Tetttative only- moat bo confirmed) <br />® CHECK BOX TO EXPEDITE REQU:-ST - $93.00 FEE (CASH OR CHECK ONLY) - REauesT PROCES$FD IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT � < �,� -� DATE <br />UNIT DISTRIBUTION ❑ Unit 1 IC Unit 2 ❑ Unit 3 © unit 4 ❑ Unit 6 a Unit 6 4 Other (electrorilC/Nstsfmapsj <br />_ <br />FILE AIVRESS EHD USE ONLY K <br />Strep! Name city <br />AV <br />4, <br />i" <br />Specific Date Range of information Reca;aested: From _ <br />t0 <br />t~N ARONMENTAL HEALTH DEPARTMENT FILES <br />0 UNDERGROUND TANK (UST) CLMUP !SITE (L11Pj 0 HOUSING ABATEMENT 0 SOLID WASTE FACILITYNEHICLE <br />OTHER CLEANUP SITE (NUN -LOP) ❑ FOOD FACILITY 0 WASTE TIRE <br />UNDERGkOUNDTANK (MONITORINWREMOVAL1 ❑ DOG KENNEL ❑ DAIRY w®� WOO <br />CI HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH CI WASTEWATER TRI=ATME,NT PLANT WOO <br />❑ TIERED PERMITTED FACILITY 13 MOT"OTEL ❑ PUMPER TRUGK/YARDICHEM TOILETS <br />0 TATTooJBOpY PIERCING 0 POOLISPA © LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACIL.ITy MOTHER (PLEASE SPEWYU t,C`'ICaI as -" t !?vt- �� �j a Ig i`A or) !tL <br />WELL AND SEPTIC PERMIT RECORD i!6 ARE AVAILA13LE FOR REVIEW - MONDAY -FRIDAY 8:00 Alt"!00pM - EXCLUDING HOL WAYS, <br />1. List up to ten addresses in the sl,iace above. Select the type(s) of files from the list above by checking the <br />appropriate box(es). At least onus file type MUST be selected. Fax to 209 4840138 or mail to the address <br />indicated above. Address rangea 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 1=HD will notify the applicant V any EHD files exist. An appointment for review will be confirmed <br />approximately ten (10) days after receipt of application. The files will be held for a'maximum of five business, <br />days for review. Appointments s Mould be scheduled accordingly, <br />3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new <br />application may be submitted wfton 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 f�illerrevie/ws by 1rhe same applicant may require a $93.00 deposit prior to review. <br />.r <br />...... - <br />EHD 40.024OG <br />11123!04 <br />