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MODESTO ATC PAGE 02 <br /> 12/16/2003 17:54 209'0- 225 PAGE GE 02 <br /> umt <br /> SAN JOAQUIN COu 9 0 <br /> EN,rMONMENTAL HEALTH DEPARTNaNT <br /> 3114 E Weber Ave 3'1 Floor Stockton, CA 95205 I— <br /> (209)468-3420 F : (209)464-0138 Web:www.CO.San-Joe4uin•ca us/ehd <br /> c i 0 5 <br /> PUBL C RECORDS RELEASE APPLICATION <br /> APPLICANTJ�� BUSME991AOENCY: <br /> ADDRESS: <br /> PHONE: ` _FACSIMILE: <br /> (PNlaaa <br /> 663 Tlm : <br /> TENTATIVE'APPOINTMENT DATE: <br /> allw 10 bwln �ft4� t Cd <br /> aubmittaq <br /> ❑ CHECK BOX TO EXPEDITE REQUEST•$83.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> DATE <br /> SIGNATURE OF APPLICANT Dsp ubnant Use OHY <br /> UNIT <br /> FILE ADDRESS b <br /> } o Unit 1 <br /> i, ao-.w <br /> z. 3 Unit <br /> ., ay.. Unft 3 <br /> a. ay.e a <br /> e. 9UeY G <br /> Unit 4 <br /> nd 5 <br /> io. sra« <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> El SOLID WASTE FACILITY <br /> NDERGROUND TANK(UST)C UP SITE(LOP) ❑O F�FACIL�ITY�HENT ❑ SOLID WASTE VEHICLE <br /> TIER CLEANUP SITE(NON�OF ❑ DAIRY <br /> ❑ ppD KENNEL <br /> DERGROUND TANK(MONrtGI�MOVAL) C] CHICKEN RANCH ❑ PKO TREATMENT PLANT <br /> �')•{AZgRDOUS WASTE GENERATORRRRRR ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ TATTOOIBODY PIERCING ❑ OTHER(PLEASE$PECIFh <br /> ❑ MEDICAL WASTE FACILITY <br /> 1. above. select the types) of files from the Ilat above by ehsekln! <br /> List up to tan addressee In the specs <br /> the appropriate box("). At least one fila type MUST be selected. L411S <br /> to 12091404-0138 or ma I t the <br /> addres Indicated above. <br /> y. EHD will notlty the applicant H any EHD files exist An aPPode m after racelp of alConfirmed <br /> pp catlon The files <br /> approximately flue business Jaya but no later than ten (10) ya <br /> will be held for a mmlimum of five business days for review. Appolntmenfa should be scheduled <br /> accordingly. <br /> no <br /> 3. Aflle that la actively being worked on by EHD staff may not be Immediately available for review• ons <br /> appllcatlon may tie submitted when the file is available. anizsd b EHD staff at the exp <br /> 4. of the lapp Ican Future fl e reviews by the same applicant may affth EHD . a E93 00 deposit prior to evle, . <br /> mG <br /> 5. <br /> Applications retie ilved after 3:00 pm wintment dates must ll be proceessedithe next business day. <br /> TIME - <br /> CONFIRMED pPPOINTMNT PATE <br /> PHONE FAX-' �N1TUtL$ <br /> DATE f;ONF1FtMED REVIEW DATE, <br /> REVIEWED <br /> YES NO <br /> rr,o wawa - . <br /> e� <br />