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�2e�I7P1M'JUAt;�l;,FIRU, UL11 L'Y <br /> NVIR6NMI55NTAL HEALTH€'ISEMENT <br /> Mafia St. stokLa <br /> cn, cA bs�oz'so2g. <br /> T Iepliorfe: (2D0) 4.68 3420 Fax: ( 0 X64-0138 Web;.vv3,rw:s1gav:0cglehd <br /> PUBLIC 14800 DS RELEASE APPLICATION f <br /> AF'PLICAt�T: ! 8USIN88VAGONCYcADDi <br /> 3, <br /> CiTYI5TATE7Z1P. <br /> PHONE (1): <br /> -Ll "4 � t31 AH06VE(2}: FACSIMILE: n <br /> TENTA77VEAAPPOINTMENT QATE. <br /> :dateofp : Time;{Pfialloy 10 b(rslnets'days fro-iottveoy- <br /> trust be.coi_f rmod) <br /> ❑ CHECK BOX Tb:EXPEo1TE REQ'Up 5725 f=EE{CAS !0k-CHECK R[QUEV'P C>CESSED IN 3 BU 1f�1;S LAYS <br /> SIGNATURE'OF APPLICANT ; <br /> �: �� � �. DATE_ � ::.� ��; I <br /> - , <br /> Electronic Informatlo'n: d list❑Map--E]escf16tion; <br /> FILE ADOkL88 ; END USE ONLY <br /> Street I Street Name .� city <br /> _. UnIt 9 <br /> 2. T r <br /> - _ Unit 2 <br /> 3• �l <br /> 4.6. <br /> td6jilt 4 <br /> 8. <br /> A - fJnrt S <br /> 'L 0. �a `t Unit 8 , <br /> S'ecific:'Date Range of 10 rniaflat�Requested: Froril <br /> n � u -- <br /> EN.V1RONhi'iptITALHEA 711:11=IRARTMENT FILES-� <br /> NOE,RGRouw TANK(UST)CLEANUP S9E(L.dP) ❑HOUS. FG ADAT1 fAENT [ OLIa'WASTE FACiL17Y1VEflftE <br /> OTHER CLEANVP SITE(NON-LOP) ❑FOOD-FACCL4Y , ❑WASTE TIRE <br /> NAERGROUNRTANK-(MON1TORING)RtMOVAE) ❑DOfs KENNET. QO-jAIEiY <br /> . <br /> AZARDWS WASTE GENERATOR' ❑CI#JGkEN RANCH YYA$TEVIfATEE2 TREATFAi:NF PLANT <br /> TI1:RE D PERMITTED FACILITY ❑MoTEt1H0TFL .'PO4PERTk,6ckI1�ARf?ICIlitiA#CAL ToltETS <br /> ❑TATT6618OaY PIERCING ❑!'40LISPA ❑LAD USS i PP41CATloN SIYF-S <br /> ❑ <br /> MEDIC:AI WASTE F.AGILITY [ CofitPLi4ltdT RECORDS, ❑6iAER(PLEASE,SPEC 1FYy t <br /> WELL A'ND SE?TIG PERMIT REC.0kDLS ARE AVAlI A #E i oR.R v114W' MoNiSAY-FRiQAY 8 t7d Alw S::�QPf�1°(�KCLvDING HOLIUAYS) <br /> 1. Ustiup to ten addresses`in <br /> the'space.above Select the ty)as{s)'of flies frarrt the,:list,abgve;by:Cheeking'the appropriate <br /> bbx(ds). At leash one'file,type MUST W'selecfed:.Fax ta' 209 4&4.09 3 ':or fbAll to the;address.r` `tcated.aboue. Address <br /> ranges will not be accepted-f&hdditionaf asststanCe with fI e,adtlress_es.,`,con`tact tha:. ! D. Appk;(Vofts r6Celved after <br /> 3:00.pm wlif b'e procesSecL the riezt b.usi,nm' <br /> day: <br /> 2. The fEHD Will notify the appficantif any, i )f#les exrst -An appointmet3f for review will bo can€irmett;aPproxiinately teri(1G) <br /> days after rete#pt'of°appilcatfon. The files will i ;held'.For a riiaxiiuum of five bus#riess;days'for revfeuv. Appoii#triTents <br /> shgniI ld be scheduled accordingly. it <br /> - 3. A filo that is actively being worked-on-by FHD-staff may not be.imrnediately avallabte:for review. Anew xpplicattian inay be <br /> submitted when the file is ay.aiial le: € <br /> 4. Ariyfile not returned In the sarne condition as released will-be reorga{iizvd by,EH13.staff at-th.e expense.of tfie.applicant. <br /> Future File reviews by the same applleAht may require,a.$125(fepostt prlor to review; <br /> EVto 4MG — <br /> I <br /> —`—' 8dlfft <br /> r <br />