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M r LUVb L:hIFM W- '! EARTH TECH _ N0. 5926 P. 2 <br /> 11'-1 71 <br /> SAM JO.A,QUIN OUNTX EHD LOG NUMBER <br /> MAR ENVIRONMNX'AL SAL M D I <br /> �PARTMENT <br /> �3E-tiT HEALTH 304 East'S�Weber Avenue,3` )Floor, ektOn,CA,95202-2708 <br /> PE R if,0,1 �: Telephone:(209)465-3420 Fax: 209 4 138 Web:wwwsjgov.org/ehd 2537 <br /> PUBLIC 12ECORDS RELEASE APPLICATIM <br /> APPLICANT: N SIN AGENCY. <br /> ADORM; <br /> PHONE(7): PHONE{2}: - p�" ACSINAILE: r te.-. <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> {Please allow 10 business day*from d codon a miftl-"TenbUvo only-must be confirmed} <br /> L� <br /> CHECK Sox To IEXPPDITE RE -593.0 {;;�CH K ONLY}-REQttESr PROCESSED IN I BUJINESS DAYS <br /> SIGNATURE OF APPLIC T DATE 4 <br /> f11117blSTRiBUIION Q Unit1 ❑L1nit2 ❑Unit Unit4 13 Units p Units ❑ Oth¢r(olsrKronicllists/maps) <br /> FILE ADDRESS <br /> street Street Name F_HD USE ONLY <br /> �I 0 <br /> F32_ D 1 4` ��s <br /> 6. <br /> 91 10 <br /> 10. .0 <br /> Specific Date Range of Information Requested:From tD <br /> ENVIRONMENTAL HEALTH Q ARTMEN'T�FILES <br /> UNDERGROUND TANK('UST}CLEANUP SETT:(LOP) 0 HousiNG AeAmm "1R SCUD WASTE FACILITYIYE-MOLE <br /> OTHER CLEANUP SITE{NON-LOP) ❑FOOD FACIIdTT 17 WAM T11M <br /> n1NOERGROUND TANK(M0ffl FOit WR&vOvAL) M Doe KENNEL 0 DAFRY <br /> "HAZARDOUS WAM GENERATOR 0 CHICKEN RANCH E2 Mt5rEwATER TRSATMENT PLANET <br /> TIERSD PE:R rr ED FACILrrr 0119oMMOTEL C3PUfAAER TRucaUYAROFCHEMI TOItET3 <br /> TArroalEoDr pIERDENc a POOLISPA X LAND USEAPPUCATEON SITES <br /> E3 MEDICAL WASTE FAC3LHTY 0 0TrHER(PLEASE:SPE FY) <br /> - WELL AND SQ"C PERMrr RECORDS ARE AMLAuLE FOR REVIEW- M0 Y-FfUDAY B:00 AEW-5:Uopm - EICCLUDENG HOLIDAY$. <br /> 1. List up to ten addresses in the space above. Select the type s)of files from the list above by checking the <br /> appropriate bax(es). At least one file type MUST be selected Fax to(209)464-0138 oI nail to the address <br /> Indicated above. Address ranges will not be accepted—for dditional assistance with file addresses,contact <br /> the EHD.Applications received after 3:00 pm will be process d the next business day. <br /> Z The EHD will notify the applicant if any EHD files exist An al pointment for review will be confirmed <br /> approximately.ben(10)days after receipt of application. The ties will be meld for a maximum of five business <br /> days for review. Appointments should be scheduled accordi 1gly. <br /> 3. A file that is actively being worked on by EHD staff may not b 9 immediately available for review, A new <br /> application may be submitted when the Tile is available. <br /> 4. Any file not returned In the same condition as released will be reorganized by EHD staff at the expense of the <br /> applicant. Future file reviews by the same applicant may req ire a$93,00 deposit prior to Review. <br /> u <br /> FFHD4602-04E9 A <br /> mf1ao5 <br />