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TE <br />0J�04- 20101 11 313AMFR3K <br />_ '--? S -'1l} - i! � LIIV LLn+ItU4iUa.li <br />=.4h1 dQENVIRO MENTAL HEALTH DIVISION RVICES <br />t 304 EASTVti E512R AVE;1VlJf THIRD FLOOR �I <br />�F .2 STOCKTON CA 95202 <br />(208) 488-3420 <br />C RECORDS RELEASE APPI,ICA-rJON — <br />TANT �i:aJl�+t� l]"1M UU- i <br />B UStNESS/AGENCY <br />TE <br />ADD SS � t V.92 N04A-1 Quu--�IP<fz iJ� u \ <br />PHOR i g�Q ' 1 aQ FACSIAMILR y J 5) <br />Ti_NTA`CLVE` ApPOLNTtAw DATLI <br />(Plaada gave 7 to 1107busuv s d S- Ir" CFdW Of -PI <br />CHECK SOX TIO EXPEDRE REQUEST- $ST.134 FEE - REQ131=S'i PROCES D I 13 <br />SIGRATURE OF APPLICANT <br />. i3LP% <br />01 <br />IS <br />O .-- <br />ipt i —r '^ �s-2fa <br />q9 -1L�,ul <br />TWA � po <br />titian bubtnistnl) <br />USIR SS DAYS <br />HATE <br />TiilS s1bE E140 STAFF USE ONLY <br />PROGRAM ELEMEHTS SEARQ." <br />Y <br />240 our • CAL I FiDOZUJA►-eE.G--r- <br />j�.9.00 <br />51 <br />LIN E913ROUND TANTS (LJS'l� GLEA.we stTE (LQP) Cy HOUSING ABATEMENT 5OLJD WASTE FACILITY <br />4ER CLEANUP 57E (MON-LOP) D FOOD PACJL ITY � SOLID WASTE VEHICLE <br />UNIpERGROUNP TA"K (MONITORINGIREMOVAL,) 13 1306 KENNET. HAIRY <br />HA RDoUS V4NSTE GEN ERATOA 0 CHUCK([ RANCH PKC; TREATMENT PLANT <br />TIE,RP-o PERMITTED FACILrTY ❑ MOTEUHOTEL PUMPeRTRVCKiYA9MHEMT0jl.IwT3 <br />TIO TAIT001BODYPEIRCING a PCOUSPA LAND USE APPIJCAT1OttSrYES <br />0 'MV ICAL WASTE PAG1LrrY 0 PUBLIC WATER SYSTE I� M OTHER (PLEASE SPECIFY ABOVE) <br />1. List up to -ten address" in the space above. Select the type(s) of fibs from the list above by checking <br />the appro}7rlat¢ bax(es}.i At least one file type'MUST be seiet:ted. faxof (209} 46"138 or mail tg't e . <br />12 <br />3., <br />4. <br />5. <br />6. <br />gs1dress, indicatoo Aboye- <br />EHD rn w notify the applicant If any F:8D files exist An ap; <br />approximately tive busirwas clays but no later than barl {1t <br />will be hetd for a rnaximurn of five business days for ravlo <br />accorgingiy, <br />A file that is actively baing worked on by END staff may n <br />applicatiah may be subrhitted when the file is avallable. <br />Any file not returned us the carne condition as released wi <br />of the applicant. Future f ile reviews by the same applican <br />`TENTATIVE appointmerit dates must be confirmed with I <br />Applical'tons, received after 3:00 prn will be processed the <br />)lntrnertt for review will be confirmod <br />days after receipt of application. .The files <br />Appolntriiaats should tae scheduled <br />be irnmodiately available for roview. A new <br />be reorganized by EHD staff at the expert. -w <br />may require a $37.00 deposit prior to review. <br />ID staff. <br />ext business day. <br />.004iRMED APPo(I mENT DArE TIME <br />DATE CONFIRMED PHONE 11 FAX <br />=mow war) YSS by REVIEW DATE <br />3' <br />h, <br />IN1TiAL5 <br />TOTAL P.01 <br />