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10/04/2002 11:12 209-579-2225 MODE5T0 ATC PAGE 01 <br /> 010 SAN `lOAQU1N COUNTYPUBLIC HEALTH SERVICES ,•1N.4u4 igtl�f.r.r• ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE.THIRD FLOOR <br /> STOCK70N CA 95202 <br /> (209)468-3420 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT r <br /> I�by PX� _BUSINCSSfAGENCY Tc "� <br /> ADDRESS ' I'I l� LOrr¢ A te, // 11 o�iw cr 7nM_ � c Dj <br /> t � r�G � r'lo`d t <br /> PHONE OQ S 7z Z FACSIMILE 22,Z 5ZOt � S <br /> _ u <br /> TENTATIVE"APPOINTMCNT DATL= U"� — UZ TH <br /> (Plcasn e+ e 7 l0 10 business TIME 10 _ PERMIT/SE uIC�S <br /> ys!r dale o pl,lleallon subrnlllai) <br /> CHECK BOX TO,EXPE=piTE REQUEST- <br /> D FEE REQ STP l�SE N 3 13 <br /> USING55 DAYS <br /> SIGNATURE OF,APPLICANT <br /> ' DATE <br /> FILE ADDRESS THIS SIDIr EHD STAFF USE ONLY <br /> Greer <br /> PROGRAM ELEMENTS SEARCH <br /> a Md IS f �d S. Es <br /> JAL <br /> f''lar <br /> B 't SAC Se 2353 T L 7 <br /> Ce+ ev 5 O TYAc r <br /> �C••re r..l' �35W as .n '•y S <br /> r vart. <br /> 'RM 3 3SO T►ti,c 8 S. Tvp <br /> T <br /> 4 <br /> ENVIRONMENTAL HEALTH DIVISION PILES <br /> UNDERGROUND TANK(VST)CLEANUP SITE(LOP) 0 HOUSING AIIATEME-NT O <br /> ❑ FOOD FACILITY SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) <br /> UhID :RGROUND TANK(MONITORING/Rr-m6VAL) ❑ DOG KENNEL E3 SOLID WASTE VEHICLE <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ DAIRY <br /> ❑ TIERED PERMM-D ❑ CHICKEN RANCH C3 PKGTREATMENT PLANT I <br /> © TATTOOIBODY PIJFACILITY IRCING ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEMTOILETS <br /> C7 MEDICAL WA5T4`FACILITY ❑ POOIJSPA 0 LAND USE APPLICATION SITES <br /> 0 PUBLIC WATER SYSXEM ❑ OTHER(PLEASE SPECIFY ADOVE) <br /> 1• List up to.ten addresses in the spats above. Select the type(s) of tiles from the list above by checking <br /> tfie appropriate box(cs).' At(cast one file type MUST be selected. Fax to 209 464-0138 or mail to the <br /> address1ndicated 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 hold 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 roturned in the same condition as released will be reorganized by EHD staff at iha expense <br /> o the applicant. Futuro filo reviews by the same applicant may require a$87.00 deposit prior to review. <br /> 5. "TENTATIVE appointment date's 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 <br /> TIME I <br /> DATE CONFIRMED PHONE <br /> FAX INITIALS <br /> REVIEWED YES NO <br /> ex oo �� +ro roe' REVIEW DATE <br />