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Lea-f'ha,3e Ln.-i roamed td.i _ i s. FAX X10. : 209SIG902 95 .. 1'i,3 r. 1 2000 01:26PH P2 <br /> SAN QUIN COUNTYPUBLIC HEALTH 5--.VICES LHOLOU r+VM0[A <br /> [r Tear ENVIRONMENTAL HEALTH DIVISION (Jv <br /> n O 304 EAST WE13ER AVENUE,THIRD FLOOR <br /> J STOGKTON CA 95202 <br /> C <br /> - - - (209)46$x.420 � <br /> f /PUBLIC FZECORDS RELF-ASE APPLICATION <br /> APPLICANT rd Burd BUSINESSIAGENCY <br /> Ao©REsS r s293lr , <br /> � 4' — , <br /> PHONE ��,.,- FACS / �� ��' � �.► <br /> TENTATIVE"APPO:NTMICNT DATE Y/ �/ /�� TIME <br /> (Please aivo 7 W 10 business days from date of applieallon subrnilial) <br /> 1 CHECK BOK TO EXPEDITE REQUEST-$78.00 FEE-REQUEST PROCESSED[N.3 BUSINESS DAYS LMAR <br /> SIGNATURE OF APPLICANT DATE e'7 <br /> r 3 VILE ADDRESS <br /> 21�- <br /> a, 2 Iii r ds4 I <br /> :=r --- MA 2-3 2006 <br /> ENVIRONMENTAL HEAI-.TH DIVISION FILES <br /> UNDERGROUND TANK(UST)GLEANIJP SITE-(LOP) 0 HOUSING A13A-TEMENT 0 SOLID VVA3TE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLIO WASTE VEHICLC <br /> UNDERGROUND TANK(MONITORINGIRFMOVAL) ❑ DOG KEXNEL ❑ DAIRY <br /> IIAZARDOUS WASTE GENERATOR ❑ CHICKr-N RANCH M FKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED EACILiTY ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARD)CH17M TOILETS <br /> 0 TA7Tpp19ODY PEIRCING Cl POOL/SPA © LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY 0 PUBLIC WATER SYSTr_M ❑ OTHER TLEtSC SPECIFY ABOV15) <br /> 1- List up to ten addresses in the space ab©ve. Select the typo(*) of files from the list above by checking <br /> the appropriate box(es). At least one file'type MUST be selected. Fax to (209) 464-0138 or mail to the <br /> address indicated :above. -� <br /> 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> approximately five business days beat no later than ten (10) days after receipt of app;kation. The files <br /> Will be held for a maximum of five bz sjness days for review. Appointments should be scheduled <br /> accordingly. <br /> 3. A file that is actively being wcr�zd on by EI-ID staff May not be immediatOy available for review- A new <br /> anpiication 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 <br /> of the applicant. Future file reviews by the same applicant may require a $78.00 deposit prior to review, <br /> 5- 'TENTATIVE appointment nates inust be conf[rmed with EHD staff. <br /> 6. Applications received after 3:00 pm will be processed the next business day. <br /> i <br /> CONFIRMED APPOINTMENT DATE TIML <br /> DATE CONFIRMED PHONE FAX INIVALS <br /> REVIEWED YES NO REVIEW DATE <br /> "'cH vo'3e a„os�oa <br />