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CT 13-2004 09 99 G "nOR:FARTH TECH 209 532 0773 ' P.eiiO <br /> GATE RECEIVED _ y EIiD LOG NUMEA <br /> SnlvJoaQiinv'COVNTx - <br /> '' ENvM0rjyffNtAL111ALTHDEPARTYMNT <br /> 0 C T 12 2004 304 E Weber Ave P Floor Stockton, CA 95205 6 7 Z <br /> (209)468-3420 Fag: (209) 464-0138 Web:www.Co•llan joaquia.Mus/ebd Z GGG <br /> EIV 11 ( 'i 'v;E 'ritil H <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT:_i auslREss/AGeNCY: R 1 TH- <br /> E '� CLIC <br /> ADDRESS! � �) �rt>= 3Qc `Q <br /> �� OLb 0 FACSIMILE:PHOI <br /> �s.�—� `t�• "'� <br /> TENTATIVE"APP�INTMENTDATE- S CJ� ` �YocrXTf <br /> o Tlme: SS:dD AM_ <br /> (pil allow 10 business days trom date Of aPPrial °n subm0tat) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$'93.00 FEE–REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> DATE <br /> SIGNATURE OF APPLICANT Dever Use Ordv <br /> RlLrrmy <br /> ilADDRESS -JYSOUDWASI <br /> 1111TH "3 <br /> s �...� <br /> z seems / - <br /> .. seaa OD L N RD >Al <br /> ENVIRONMENTAL HEALTH DEPARTMENT ILLES <br /> XL UNDERGROUND TANK(UST)CLEANUP SITE(LOP) O NG FOODIFACIRM ABATEMENT 7o SOLID WASTE VOUCLE <br /> M <br /> OTHER CLEANUP SITE ON-LOP) DAIRY <br /> UNDE RGROUND TANK(MONITORINGMEMOVAL) CI NCH <br /> te HAZARDOUS <br /> pKGTREATMENT PLANT <br /> Q$HAZARDOUS WASTE GENERATOR ❑ MOTEMOTEL ❑�./PUMPER TRUCK/YARDICNEM TOILETS <br /> gr TIERED PERMITTED FACILITY C1POOL/SPA }r LMD USE APPLICATION STIES <br /> ❑ TATTOOIBODYPIERCING O OTHER(PLFASESPFCIF`n <br /> ❑ MEDICAL WASTE FACILITY <br /> 1, List up to ten addresses in the spate above. Select the type(s)of files from the list above by oheddni <br /> be selected. Fax to(2 <br /> the appropriate box(es). <br /> At least one ills type MUST 091 d640f38 or mail to the <br /> address indicated above. <br /> 2. EHD will nctKy the applicant if any EHD files exist to 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 acthrely being worked on by EHD start may not be Immediately available for review. Ane' <br /> application may be submitted when the file is available. the ex at Pan <br /> 4. Any <br /> iile not returne in <br /> future file reviews by the same applicant same condition as released )may reqube ire a$93.00nized 1depa�prior to revill <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 <br /> DATE CONFIRMED <br /> PHONE,. '0AX INMAL5'' j <br /> REVIEWED YES NO REVIEW DATE TOTRL P.01 <br /> I <br />