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0 <br />1234 KLEINFELDER 13:14 06-29-2010 <br />DATE RECEIVED <br />QAUIN COUNTY <br />EALTH DEPARTMENT <br />ast` . ckton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/eh <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: r <br />PHONE (1): 7) 11- y J 7 PHONE (2): FACSIMILE: <br />TENTATIVE' APPOINTMENT DATE: Time: <br />(PNase allow 10 business days it date o1 a lieatlon submNtal • 'Tentative only -must be confirmed) <br />. CHECK BOX TO EXPEDITE REQUEST. f1 55. 0 41 OR <br />SIGNATURE OF APPLICANT <br />L Electronic Information: ❑ List ❑ Map - Description: _ <br />1 /1 <br />LOG NUMBE <br />31 <br />ONLY) • REQUEST PROCESSED IN 3 SUSINES DAYS <br />DATE 6 aa0 <br />On <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />DIC T <br />.��� <br />'UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />P'OTHERCLEANUPSITE(NON-LOP) <br />O HOUSING ABATEMENT <br />13 FOOD FACILITY <br />13SOLID WASTE FACILITYNENICLE <br />0WASTE7IRE <br />1 _I'1.?�- <br />I�INDERGROUND TANK(MONITORINGIREMOVAL) <br />13 DOG KENNEL <br />13 DAIRY <br />IWI /)11 <br />=�HATARDOUS WASTE GENERATOR <br />�i <br />0 TIERED PERMITTED FACILITY <br />❑CHICKEN RANCH <br />0 MOTELIHOTEL <br />EIVASTEWATER TREATMENT PLANT <br />13 PUMPER TRUCW <br />0 TATTOOIBODY PIERCING AR HEM oILETS <br />I OOLISPA ,l3rAND USE APPLICATION SITES <br />0 MEDICAL WASTE FACILITY O OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR RENEW - MONDAY -FRIDAY 8:00 AM•5:00PM - EXCLUDING HOLIDAYS. <br />1. List u0 to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate <br />box(es). At least one file type MUST be selected. Fax to 12091484-0138 or mail to the address Indicated above Address <br />3x00 pm wlnges llnot tl be processed thaccepted - eor next nett business day.ional �,?. tl )Ie �dr neswonta ct the EHD. Applications received after <br />2. The EHD will notify the applicant If any EHD files exist An appointment forreglew will be confirmed approximately ten (10) <br />days after receipt of application. The files will be held for a maximum of five SUslness days for review. Appointments <br />should 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 appllraUon may be <br />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 applicant. <br />Future file reviews by the same applicant may require a $105.00 deposit prior to review. <br />EHD USE ONLY <br />"""If you need further assistance pleose contact Diane Martinez @ (209)168-3425 directly. Thank You'"W <br />o/0Irdant a.01Pl I' Cwt Q COPS of CO <br />K6 <br />