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MA K. 1 LUU4 1:51 NM CU: , EARTH TECH N0. 5926 P. 2 <br /> SAN JOA►QUIN OI;NTY EHD LOG NUMBER <br /> ENVZRom NTAL HEAL rH D)wARTMENT <br /> � ALF 304 East'W'ebcr Avenue,3`d Floor, cicton,CA 95202-2708 <br /> Telephone:P (209)468-3420 Fax:(209)4&.-0138 Web:wtivw.sjgvv.orglehd 253 7 <br /> PUBLIC RECORDS ULE SIE APPLICATION <br /> APPLICANT. kyr o =31NAGENGY; <br /> ADDRESS: `{ � (l yh <br /> PHONE(1): y PHONE(2): •W9- a1- � ACSiIUEILE: �ISP r - <br /> TENTA ME"APPOINTMENT DATE: <br /> (please allow 14 DueEnesg days from d cation sEr mild-"Ten(alfvo only-moat be collRrtned) <br /> d CHECK SOX To EXPEDITE RE T-$93.0 EE( CHECK ONLY)-REQUEST PROCESSED IN I SU (NESS DAYS <br /> SIGNATURE OF APPLIC T DATE Q� <br /> UNIT DISTMSU71ON ❑Unit 1 0 Unit 2 E udiE Un1t a ❑Unit 5 E3 Unit s d other(alaetron'rellisCslmaps) <br /> FILE ADDRESS <br /> Street# Street Name EHD USE ONLY <br /> F34 <br /> t r o -r ,o f �q5 <br /> 6 <br /> 7. <br /> 10 <br /> SPOCIfic Date Range of Information Requested:From � <br /> �J ENVIROi•1i19ENTAL HEALTH DEPARTMENT FILES <br /> }�,UNDEROROUNa TANK(UST)CLEANUP SR&(LOP) 0 NOV-SING ASATEMM �S)LID WAwm FACILrfYNEmcLB <br /> OTHER CLEANUP SITE(NOM-Lop) ❑FDOo FAC[Lfrr ❑WAM TIRE <br /> NDEAGPEOUNO TANK MOMTORING{fiGM0vAL) a Dpo KFJmNFL Cl DAIRY <br /> HAZARDOUS WAS'T'E GF,NMAATOR LZ CxtCKEH RAMGH !=7 WASTEWATER sA7fAEPI'TPLANI• <br /> 7 ERE0 PORMU ED FACELnY a MOTELINOTEL E3 WAS'rPUMPER ATER TYA[xe <br /> 0 TATTOW1300Y PIERCING ❑PQQtf$pA 0 LAMP I IUCKNAPPljCAT[O��O[LETs <br /> ❑MEDICAL WASTE FAaE I rY 17 OTHER(PLEASE SPE <br /> WELL AND.SePT[C PERM;T RECORDS ARE AVAILABLE"FOR REVIEW- MOM Y-FRIDAY S:W AI4S:oopM - EXCLuD[NG HOUDAYS. <br /> 1. List up to ten addresses in the space above. Select the type )of files from the list above by checking the <br /> appropriate boX(es). At least one file type MUST be selected. Fax to 209 464-0138 or mail to the address <br /> Indicated above. Address ranges will not be accepted—for dditional assistance with file addresses,contact <br /> the EHD.Applications rec6ived after 3:00 pm will be process d the'next business day. <br /> 2, The EHD will notify the applicant If any EHD fifes exist An a pointment for review Will be confirmed <br /> approximately.ten (10)days after receipt of application. The Iles will be held for a maximum of five business <br /> days for review. Appointments should be scheduled accordi gly. <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 when the file is.available. <br /> 4. Any file not returned in the same condition as released will be reorgantaed by EHO staff at the expense of the <br /> applicant. Future file reviews by the same applicant may recl ire a$93.00 deposit prior to review. <br /> _ r J1 U <br /> REHD 4N2-= <br /> F 74�� <br />