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%-1'1-ci1)Ui U_'_:UHPI H.Ojl <br /> SAN AWIN C0UN-fYPUT3LIC HEALTH SE •ICES u,a4 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> _304 EAST WEBER AVENUE,Ti}1RD FLOOR (l <br /> STOCRTON CA 85202 <br /> (200) 468.3420 <br /> PU$LlE RECORDS RELEASE APPLICATION n F - <br /> APPLICANT eUS WESSlAGENGY ���,�� TQ�I�(�' <br /> •AnbR65S .t.-y�cc � lf/� � 1 �y <br /> PHONEq FACSIMILE <br /> i <br /> TENTATIVE'APPOINTMENTDATE _ [ J��O'"[ J' -nMa D 1 , Y-n-(f, <br /> ' {Plca�e 0ivc7ta t0>ausiness days tram sa�te of appGcallpn SUh.++uLt) l.J�� <br /> CHECKBOx TOExPEDrrti R�gUEST ,00 IZEF-REQUEST PROCESSED IN 38USINE5S DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> FILE ADDRESS - THIS SIDE eilb sYAFF USE ONL _ <br /> ' � PRQGEWM LI.El,IENTS SCAftCN <br /> `ta rid r <br /> V <br /> i <br /> i <br /> d <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> VNDERGROUryD TANK(LIST) CLEANUh SITE(LOP) ❑ HOUSING MATFMEAT SOUL)WASTE FACILITY <br /> In <br /> ❑ FOOD FACILITY ySOUD WASTE VEHICLE <br /> EMOVAy ❑ DOG KENNEL � 0 DAIRY <br /> ❑ CHICKEN RANCH O FKOTREA7i•LENTOIPNT <br /> EREO PERMITTED FACiLiTY ❑ MOTELMOTE. 0 PUMPER TRUCVJYARDlCHEMTOILET2 <br /> O', TATTOOMODY PCIRCING i 0 POOLFSPA --- ❑ LAND U56APFLICATI"SITES <br /> Q MEDLCALWA.g1EFACILITY 0 PUELICWATERsYSTPN 0 OTnER IPLEASP_SPECIFY Ao4VE) <br /> (. List Up to ten adCrassas,ln the space above. Select the type(s) of files from the Ilst above by chocking <br /> Vie appropriate box(CS).'.At[east one file type MUST be selected. Fax to f20SS d64-0738 yr mail to the <br /> ijddresa indicated above! <br /> 2 EHD will notify the Dppllcant If any EHD files exist. An appointment for review <br /> will be canfUrrlod <br /> approximately five busilzess days but nQ later than ten(10)days afterreceipt Of application,-The tUes <br /> will be held for at maximum of five business days for review. Appointments should be scheduled <br /> accordingly. ; <br /> 3. A FIR that is Aotlyuly being wDrkca Qn by EMU staff May not be imnlRdlately available far rel&w. A new <br /> application may be sabMitted When the file is available. <br /> '1. Any file not returned 11100 same COndWon as roloased will be reorganized by EItD staff at the expense <br /> Of the applicant. Future file reviews by the same applicant may require a$87.D0 deposit ptior to review. <br /> 5. 'TENTATIVE appointment dates must be Confirmed with EHD staff. <br /> 6. Applicaywns received afQar 3:00 pm will be processed the next business day. <br /> t <br /> I <br /> PONRRMED APPOINTMENT DATE TIME <br /> I a <br /> ATE CONFIRMED PHONE FAX INITIALS <br /> i1EVI6WED YESNO <br /> n a •I ._ roe REVIEW DATE _ <br /> TOTAL P.131 <br />