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1Jy/1J1/2b1J4 12:4( 2U'3-579-2225 MODESTO ATC PAGE U1 <br /> DATE RECEIVED EHD LOG NUMBE <br /> SAN JOAQUIN COLWTY <br /> KE <br /> (n5 II }, DENVIFON-N NTALHEALTHDEPA.FTMENT <br /> SEP 0 1 2004 304 E Weber Ave 3`d Floor Stockton, CA 95205 <br /> (209) 468-3420 Fax: (209) 464-0138 Web:www.co,san-joaquin.caus/ehd <br /> E`4Vr; ,,AI'VIENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: 0('(-W QaV\ *\`�^ BUSINESS/AGENCY: AT <br /> ADDRESS: t�\� L,3-111- PaA--� LtLkl Q, Maga iso <br /> PHONE: Z� Z ZZ'LI FACSiMIL �^-Z� � s 7­7 - Zr-z-r/� <br /> TENTATIVE*APPOINTMENT DATE: -1 ' `�Li Time <br /> (Phase 811ow 10 business days from date of application submittal) <br /> El CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT f'�^'v -A ' ` DATE <br /> Lit !`I�" ✓' Si .S 'E o4-t1x-s L--X1IUSf('ec?nt Department Use Only <br /> FILE ADDRESS UNIT <br /> vC�tCitySEpcK �UStNAZ. �1 <br /> p <br /> i stmt 51 SI caL L� k.A� � s %A H ---- —� ❑ Unit 1 <br /> 0 Unit 2 <br /> 35x4 rn� .. s� ��' �n�� tc tam r r✓� �' S i Z <br /> e. 34'"t St` CK -► — 3 <br /> 3 5�� U n D. Street <br /> 11-44 G . TA,,&tLN Fd d , d Ara Lti <br /> sal -3:5 :4Un <br /> �i- PY `'e. sv.a Lta+r-L Ory <br /> S Lk <br /> 37� ?' v.et `Rt .5�-.- - 5 ❑ Unit 5 <br /> 7�7 0. sveet Si Lv'� tV� Al 5 L <br /> ENVIRONMENTAL HEALTH DEPARTMENT FiLES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) a HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> W OTHER CLEANUP SiTE(NON-LOP) Cl FOOD FACILITY d SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONrrORINGIREMOVAL) ❑ DOG KENNEL p DAIRY <br /> d1 HAZARDOUS WASTE GENERATOR Q CHICKEN RANCH O PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARD/CHEM TOILETS <br /> TATTOO/BODY PIERCING d POOLiSPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> 1, Rist up to ton addresses In the space above. Select the types)of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to 1464-0138 or mall to t;,ne <br /> address Indicated ab9ve. <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 nel <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 END staff at the expens, <br /> of the applicant. Future file reviews by the same applicant may require a$93.04 depoalt prior to revlev <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff, <br /> 6. Applications received after 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME 77 <br /> DATE CONFIRMED PHONE FAX ' . " "''" `:INITIALS <br /> REVIEWED -- YES NO REVIEW DATE <br /> eHO as-ua-gaw r <br /> annaas <br />