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FE=li-14-2005 11 17 CUIy OR EARTH TECH 205 532 0773 F'.01/0: <br /> DATE;RECEIVM EHO LUG NUN i <br /> SAN JOA,QUIN COUNTY i <br /> ENVM0NMF,1vTAL'ftEAT,TH DEPARTMENT ' <br /> 304 B Weber Ave 3rd 1~laor Stockan, CA 95205 4 <br /> 1 '4 7005(209)468-3420 Fax! (209)46"135 Web:ww-w—co.san joaquimca.uslehd � <br /> Uql NME:NT. HEALTH PUBIAC RECORDS.RELEASE APPLICATION <br /> P `' 9LI91HESSlHGEAICY; ' �1?�f + A7'+f+�` f11 <br /> APPLICANT; <br /> ADDRESS: <br /> PHOTIE� � FAcslMl►.>;: ,��;', Ll � .i"� ---- —„ <br /> O 8 os, n,,,e: O a• rn Y: <br /> r�rl-fATfVE*A�+F+OlN7MEPl'3'DATI�, � . <br /> (Please allow 10 busine"days 3rom dale 4t application oubmillin <br /> *CHECKBOXTOEXPEDITE i7Egtla;:r-$n0o FM-PEQUEST PROCESSED IN 3 BUONMS DAYS <br /> SIGRATURE OF APPLICANT DATIZ <br /> b <br /> DePWbft nt Use OnlY <br /> FILE AdDRM Utm <br /> Unit 1 <br /> x saw, 10 0 b"Z Zr. 0diA,1jT0CX, RA, MF <br /> 3. sties 1041 F- RL00 �Unl22 <br /> RA- <br /> 4. somas Z�I RA• L <br /> 7 5 r5 P i F Unit 3 <br /> SYoiC oAl 'Ti1lZN 111;A c- iF57" r7AI " r UnU 4 <br /> .,,.`� I�1L RDD ,,•.�,�`: `-;� �' <br /> a 1 aJ ,�' '' ❑ Unit 5 <br /> a suc� <br /> ENVIRONlI 0 fA.L HEALTH DEPARTMENT FILES <br /> UNDERGROUND YANK(USM CLEANUP SITE(LOP) I7 HOUSING ABA-ENIVNT f1�SOLID WAST9 FACILirY <br /> OTHER CUARUP SITE(NON-LOP) ❑ FOOD FACIt jTY /U SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONn'pRINGIREMOVAL) ,12*6 KENNEL .�DAIitY <br /> ;eHAZAROOUS WASTE GENERATOR �e CHICHEN RANCH 12 PKG TREATVE r PLANT <br /> �l TiEREI3 PERMITTED FACLLITY a MOTELIHOTEL );Y,PUMPER TRucrjYARDICHER 701LET: <br /> ❑ TATiOGIBODY PIERCING~ © POOl15PA LANA USE APPLICATION SITES <br /> C1 MEDICAL.WASTE FACPJW ❑ OTHER MY-ASE SPECIFY) - <br /> 1, Lj$t up to tori addresses in the spaere above. Select the type(s)of flies from the I"'st abnye 14y checldr <br /> the appropriate box(es). At least one file type MUST be sefeetod- Fax to Z09 46"13or mall to the <br /> address Indicated above. <br /> Z 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 tan (1 b)days after receipt of application_ The fie: <br /> will be held for a maxirnum Of five business clays for review. Appolntrments should be scheduled <br /> accordingly. <br /> 3. A file that is actively!Weida worked on by EHD staff may loot be immediately available for review- A nl <br /> application may be submltted when the file Is available. <br /> 4. Any fila not returned in the same condition as released will be reorganized by EHD staff at the expen: <br /> of the applicant f=uture file reviews by the same applicant may require a$93.00 deposit prior to-MVI( <br /> 5, '`TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications mcelved after 3.00 pm will be processed the next business day. <br /> _ r <br /> COjkF)RMrD APPO18CMENT DATE TIMI <br /> DATE CONE=li AilEp -PHONE . FAX, 1NfT X:S'-,_,-.�� <br /> REVIEWED }. lYE6 NO REVIEW DA'M' <br /> TOTAL f°.0:' <br /> i' <br />