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SAN JOAQUIN COUNTY <br /> PUllLIC IIEALTII SEHVIf ES <br /> .ENVIRONMENTAL IIF:AL'11I DIVISION <br /> PVlll,W RECOIWS RF-L&%SG APPLICATION <br /> APPI]CANT~ L <br /> cu HONE NO <br /> e��Ol l_►'1 . <br /> ADDRESS <br /> AGFNCY NAME �_ S _-___. PHONE NO _— <br /> ADDRESS--- AGENCY <br /> 11 ADD r LEAD AGCY DA'I8 <br /> mos C'orttvr s>•rec?- — _ -- -- --- <br /> LI <br /> 11115 NO'1'iL'L• !S SI II(IF:CI' :-J TH( RIVSISR E7(1HNTS [DGNTI FISD IN T}tE PUBLIC 1i F.Al:T'H <br /> SI:R VICES/EFI VIRONMI;N'I Nt.11*;ACM DI VISION(E(!D)POLICY p92 007,ORDINANCE CODE t IP SAN <br /> . <br /> JOAQUlN COUNTY. FJSD F'ErS AND SERVICE CIIAROE RESOLUTIOIIS, grmii WAIER CODE. <br /> GOVERNMENT COUB AND 11iti U-VIDFNCE CODE <br /> I. A MA:{IAIUM OF 1"EN (It,)PREMISB ADDRESSES PER REQIJFSC- <br /> 2 f'(IOIJC Fi LL•S/R ECORI)S RF;VIFW ARF RY AD'—( C—QNI,I�• 't Pl'OINI'MGN?'S ARE <br /> ARRANGED BY CALUNO (-,,ay)44S8 QJ•t0. c�FP1a:E IIOURS FOit .,,lY•GINITiISt'I S ARE SCiIEDUI•EO <br /> AIONDA.Y MIRII FRIDAY E.XCLt)DIN(IllOLJ1)AYS, 8:00 A.ht.TO I:,.tOO NOON AND 1u00 P.M. IO 4:30 <br /> P.M. <br /> 3. A PI,IRIJC RBCORUS RELGASG APl'tJCA7ION ANP A NON_2«IINOAIII • D61.0SIT OI' 578.00 <br /> IS RE.QIJIRED. DIWOSYES WII L 8E REMILNED TO THE API'LICAN'I'IF 1HE FILFS/RECOPJ)S ARE <br /> NOT AVAIL-kill-11 WITHIN THE CUStODY OF THE HIM <br /> 4. TIAF ABOVE BDENTIFIEU DEPOSIT IS APPIJED 'f0WARDS 175E TOTAL. FILE REV11i1Y :=EE <br /> CIIA.RGE. 111E BALANCE CF 111E CHARGES ARE DUE AND PAYABLE 'it1 IOJ_1'O REViEW'-NC:'CHE <br /> INoCU!(1ENf(S)• <br /> 5 1'tJtil_IC F!l.ES/RECORDS NOT R[hJRNED IN 111E SA1,1E CONDITION AS RECEIVED WILL BP <br /> CORRP.C7'En 8Y 1HE EIID STAFF' AT 11)E EXPENSE OF "111E APPLICANT. '11115 ADDI'ITONAL <br /> SERVICE WILL TIE HII]SD TO TI'E APM]CANT FOR PAYMENT- <br /> 6• ORIGINAL FUeL1C P{Lli5/i:ECORDS SHAH. NOT' BE RE•h10VED FRUAI 111F flip PREMISES- <br /> ------- _ .-- . <br /> SIGNATURE OF APPLtCAN-r DATE <br /> SIONAIVRE OF RELEASING(Tr FICIAL UA718 <br /> Ell 00 14 (REV 12192) <br />