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0 <br />APPLICANT. <br />ADDRESS: <br />C;" <br />I ` W EHD LOG NUMt3ER <br />° . •TOAQUIN COUNTY <br />'A% : 7.EN'TAL HEAu'i-(DEPARTM:JEN'-r <br />MZSt Main Street, St'O&=., CA 95202-2708 <br />Tcleplit�tl�e: (209) 468-3420 Fax: (209) 464-0135'Neb: iv-,vw,sjgov,org/ehd <br />PUBLIC RECORDS IZEL[11ASE APPLICATION <br />BUSINESS/AGENCY: AW7 <br />PHONE (1):�� %� Jt� /PHONE (2):��-� FACSIMILE:9' d ,sR'a" ;i/, <br />TENTATIVE* APPOINTMENT DATE; Time; <br />(Please allow 10 business days from date of application , ttal , `Tentative only • must be confirmed) <br />ANATD <br />HECK BOX TO EXPEDITE REQUEST - $9 00 EE (CASH OR ) QUEST PROCESSED IN 3 BU NE5S DAYS <br />4: s: <br />SIREOF API'1_ICANT _ ��y �� DATE �U <br />Electronic information: ❑ List ❑ Map — Description: <br />FILE ADDRES5 <br />EHD USE ONLY <br />Street # <br />_w <br />Street Name <br />City <br />�- <br />_ Unit 1 _ <br />co/261�r <br />4. <br />1776t <br />7,0— <br />� Unit 3 <br />N <br />..Unit 4 <br />���� `�� <br />! � <br />6 <br />7, <br />.-..,,.-, <br />.....^ —. <br />_.�.._.. <br />❑ Unit 5 <br />❑ Unit 6 <br />Specific bate Range of Information RsCC rom to <br />..1k" <br />t NMENTAL HEALTH DEPARTMENT FILES i)r <br />AUNDERGROUND TANK (UST) CLEANUP SITE (L P) ❑ HOUSING ABATEMENT O SOLID WASTE FACMTYNRHICI.0 <br />THER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY El WASTE TIRE t <br />UNDERGROUND TANK (MONITORING/REMOVAL) 94 13DOG KENNEL ❑ DAIRY i 1 <br />40.ARDOUS WASTE GENERATOR 114) 0 CHICKEN RANCH M WASTEWATER TRCATMCNT PLANT <br />Li TIERED PERMITTED FACILITY (X 0 MOTEI-IHOTFL 0 PUMPER TRUCK[YARD/CHFm ToILFTS <br />C]TATTOO/BODY PIERCING �/ 1 0 POOU$PA 0 LAND USE APPLICATION Sn-ES <br />© MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW - MONDAY -FRIDAY 8:00 AM-5:00PM - EXCLUDING HOLIDAYS. <br />1. List up 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 MV5T be selected. Fax to (2091 464.0138_ or mail to the address indicated above. Address <br />ranges will not be accepted — for additional assistance with file addresses, Contact the 1;Hb. Applications received after <br />3:00 pm will be processed the next business day. <br />2. The EHE) will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) <br />days after receipt of application. Tile files will behold for a maximum of five business 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 application 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 $98,00 deposit prior to review. <br />EHD USE ONLY <br />*** If you should need further assistance please contact Diane Martinez @ (209)46$-3425 directly, TThank You**** <br />