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10/04/2002 11:12 209-579-2225 MODESTO ATC PAGE 01 <br /> SAN •QUIN COUNTYPUBLIC HEALTH SERVICES <br /> 0 X0 ENVIRONMENTAL HEALTH DIVISION <br /> I 304 EAST WEBER AVENUE,THIRD FLOOR <br /> STOCKTON CA 95202 <br /> (209) 468-3420 <br /> 1 PUBLIC RECORDS RELEASE APPLICATION <br /> J <br /> APPLICANT KVv jer-_t_ t-,- <br /> BUSINESS/AGENCY H I G . Assarr-Ile(• <br /> ADDRESS Aalw. � a.�,i� 'Ij pt,a(es Cs' <br /> \ / OCI /\ STrVie, OCT n � <br /> PHONE �.OQ / SiZ�— 2221 FACSIMILE" `Z —Z?z'j @� <br /> PP <br /> TENTATIVE"APPOINTMENT DATE" 10 -�1 - p2, TIME IO Ary PERMIT/S 7H <br /> (Please pi O�I ku Hu ,u, inns. ERVICES <br /> ys Ir data o ppllc__,,submdlal) <br /> CHECK BOX TO,EXPEDITE REQUEST• 0 FE'RC-Q J ST P ISSE N 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT <br /> y---� DATE _/0-<- 07— <br /> FIX <br /> -<- UZ <br /> FILE ADDRESS THIS SIDE EHD STAFF USE ONLY <br /> w <br /> 6000._CIW <br /> �d rrreEY 15 S PROGRAM ELEMENTS SEARCH <br /> S. Es r, <br /> UALf'kr a $I� EJ s, <br /> s e k <br /> B S.k $e i 2.353 T -F ID 0 T , <br /> Se re, w S O Tv� T r <br /> De'x '..I of :0 X R W., <br /> 'r r N 2tt 425 Lqr4f2 TeAC <br /> 12M 3 35o Trr 8 S. Tva <br /> lo,ir Tr,aki.+ 37i'Ff(7 L;„ <br /> •a. <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> X UNDERGROUND TANK(U5T)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> X OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> X UNDERGROUND TANK(MONITORINGIRC-MOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITT4-O FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOOIBODY PHIRCING O POOL SPA " ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE• FACILITY ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1. List up to.len addresses in the space above. Select the type(s) of files from the list above by checking <br /> the apprcpriatc box(es). At least one fill: type MUST be selected. Fax to (209) 464-0138 or mall to the <br /> addrrss 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 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 /> 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 reorganized by EHD staff at lite expense <br /> of the applicant. Future file reviews by the same applicant may require a 487.00 deposit prior to review. <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> G. Applications received after 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX <br /> INITIALS <br /> REVIEWED <br /> N oo 14 Boa YES NO <br /> eREVIEW DATF <br /> s <br />