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10/041zoo2 11:12 _99_579-2.:25 I MODESTO ATC PAGE 01 <br /> SAN JOAIN COUNTYPUBLIC HEALTH SERVICES <br /> I o �� ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,THIRD FLOOR <br /> STOCKTON CA 95202 <br /> (209) 468.3420 <br /> PUBLIC RECO <br /> 1�Vh RDS RELEASE APPLICATION <br /> � ^ <br /> APPLICANT " ` --- — _ <br /> �6r�'— BUSINESS/AGENCY•_�C ��s <br /> ADDRESS 11 17JL <br /> PHONE_0_0q ) S�9- Zz2 w. C l�� Hole �O C " <br /> L FACSIMILE" 5�j-z2Z� <br /> TENTATIVE"APPOINTMENT DATE IO —ZI —(JZ V TH <br /> (Please DI e T la'10 Vu-fines- TIME !O V PER <br /> ❑ _ , , Ys rr dale o ppecallon su6nulW1) <br /> CHECK BOX TO,CXPEDITE REQUEST- 'REQ .-ST P1 5E N 3 BUSINESS DAYS <br /> . 0 FEE— <br /> SIGNATURE OF APPLICANT T��x��� <br /> DATE 10-<- 02— <br /> FILE <br /> CU"¢ OZFILE ADDRESS <br /> w THIS SID[EHD STAFF USE ONLY <br /> w 4 C+NeeY' PROGRAM ELEMENTS SEA <br /> HCH <br /> fir • vl �d S. Esc n <br /> 8075 EJ S. 1.Oq _ • <br /> ie F rwf 545$' $C<-f cin11 <br /> 8 <br /> SAC S °k �' 7 <br /> Se i 353 T�-f T a <br /> Ce, rr S O Tv,., >S <br /> Z35ty as N R Tv V <br /> -Y TY 4 dFxS 1 9 <br /> RIM L TeAc �I v <br /> 5 torr Tv�ki�3 350 Tv c 8 S. TiY V 1 <br /> v✓ v. <br /> ENVIRONMENTAL HEALTH DIVISION FILES N <br /> UNDERGROUND TANK(UST) CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ y� <br /> OTHER CLEANUP SITE(NON-LOP) SOLID WASTE FACILITY (\♦r <br /> UNOCRGROUNO TANK(MONITORING/REMOVAL) ❑ DOG FACILITY <br /> ❑ SOLID WASTE VEHICLE <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ DAIRY <br /> ❑ TIERED PEFiMITT440 FACILITY Cl❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TATTOO/BODY pZICING ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARD/CHCh1 TOILETS <br /> ❑ MEDICAL WASTI FACILITY ❑ POOLISPA 1 ❑ LAND USE APPLICATION SITES <br /> ❑ PUOLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1• List Up to ten addresses in the space above. Select the type(s) of files from (110 list above by checking <br /> the apprdpriate box(es). At least one file type MUST be selected. Fax to f209) 464 0138 or mail to the <br /> address Indic—vE <br /> 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> approximately five business days but no later than ten (10) days after receipt of application. The files <br /> will be held for a maximum of five business days for review. Appointments should be Scheduled <br /> accordingly. <br /> 1• 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 /> 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 s <br /> 'TENTATIVE appointment date ame applicant may require a $87.00 deposit prior to review, <br /> s must be confirmed with EHD staff. <br /> Applications received after 3:00 Pm Will be Processed the next business day. <br /> %ONFIRMED APPOINTMENT DATE <br /> TIME <br /> ATE CONFIRMED <br /> PHONE FAX INITIALS <br /> EVIEWED YES <br /> ao a ewrrvo NO REVIEW DATF - <br /> a, <br />