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05/01/2007 16:46 GEOMF X—RANCHO CORDQVR 12094640135 <br /> NO..753 902 <br /> f-+ EHE)LPG NUMBER <br /> DATE RECEIVED SAN J6AQUIN COUNTY g 4 <br /> ENVIRON <br /> HEALTH LDEPA�tTMENT <br /> :-- 600 E. Main.Street,Staakto�,CA 95202-3029 <br /> [ o I <br /> J , v ` Telepbo�e;(209)aG8-3420 Fay::(209)464-0138 Web;t��ww.sjgtiv i/c <br /> FUSTIC RECORDS RELEASE APPLICATION <br /> AI'f'LCCAttT: G f _ sualNE5SIAGENCY: rls�� ` <br /> ADDRE66: 40 W c C Y> CA. .�O p <br /> PRUNE{1): I �&' 21'-" PHOME(2}: • .. FACSIMII E: — Y1 � <br /> TENTATIVE'APPOINTMENT DATE: Time: <br /> (FlWa pilaw 10 tnlalrVaSS days ham dato of application submittal-'Tentative only•mugt bo cartTrmesi) <br /> CHECK BOX TO FaXPEplTl9 Re sT•$95,00 FEE(CASH OR CHECK ONLY}-REQUEST PROt;lrSSED IN s BuSINi:S� <br /> SICK ATURE OF APPLICANT, <br /> PPLICANT PATE <br /> Electronic lnfarmat}an: List[3"RAap�-Description: <br /> 00 <br /> FILE T6DRESS EHD USE ONLY <br /> Street a Street Name City Unit t <br /> l�llnit Z <br /> F22. <br /> ur�lt s <br /> 4. ,. <br /> 6' LA.N µx <br /> T. <br /> 11 <br />�- 7 1 Unit"s <br /> 9. unit a <br /> 10. <br /> rr__ <br /> AA' t <br />� <br /> Specific Dste Range of InforrnaNan Requested:From "� o — <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ',UNDEROROUND TANK(UST)CLEANUP SITE(LOP) � ` <br /> «HOUSCNG ABATEMENT 'a SOLID Waw FAOILrfYNCHK:L� <br /> OTHER CLEANUP SITE(NON4-OP) 'V«F000 FAmuYY 'QSAM TIRE <br /> `61 UNPFR(ROUIMTANK(MONITORMO1REMOVAL) `QDOO KENNEL 'QDAJRY <br /> '61 HAZA MU&WAGTE GENERATOR _ 'Q CHICKEN RANCH '-Q WASTEwATERTPEATMENT PLANT <br /> TIERED PeRAIITiED FACILRY '•MP-MuNOTEcL `a.PuarPM TRUC"ARDICHEM TOu M <br /> — LTATYGOf9C&PIERUNG` POCUSPA LIMO USE APPUOA1WF(SnS ' <br /> �G IIAEoIDAL WASTE FACILITY - OTMBR(PLEASE SPECIFY) <br /> WELL ANG srpnc PERMIT RECORD$ARE AVAILABLE FON RVIM ,MONOAY-FRICAY S: -6:ODPM • Exr-LIJOING HGUDAY$. <br /> 9. List up to ton addresses in.the space above. Select the type(s)of Rtes from the 11st above by checking the appropriate <br /> box(es). At feast anB file type MUST be selected. Fax to(ZL91 J154,008 or mail to hs address jpdicated ove Address <br /> I rangas will not 6e accepted—for additional assistance with file addresses,contact the EHD.Applications received after <br /> 3:00 pIrn will be processed the next business day, <br /> 2. The EHD will notify the applicant If any EHD flles exist, An appointment for review will be confirmed approximately tan(10) <br /> days after receipt of application. The tiles will be held for a maximum of five business days for review. Appointments <br /> should be scheduled accordingly. <br /> 9, A file that is actively being worked an by EHD staff may not be.immedlately available for review. A new application may be <br /> i sgbmitted when the file is available. <br /> 4. Any file not returned in the same condition as released will be reorganicad"5y EHD staff at the expense of the applicant. <br /> Future frac reviews by the same applicant may require a$95.00 deposit.prior to review. <br /> i EHD USE ONLY <br /> i <br /> l <br /> EHD040 9r+2i2=8 vna <br />