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Fab-li-2002 04:37pm. From-KINKO'S SWANDR4 _ 15103578053 f{� =4' ) P. � � 9 <br /> `7 �• <br /> OUNTYPUBL IC HEALTH SERVIIS <br /> MENTAL HfAl.TH DIVISION <br /> -pzl, <br /> U, WEBER AVENUE?,THIRD FLOOR <br /> STOCK170N CA 95202 <br /> (219)468-34.20 74 <br /> PUBLIC RECORDS .RELEASE APPLICATION <br /> APPL.ICtiT P BIiSfNESSIAGNCY.�,`�.r1— ,=rAr/y�+i� t . - <br /> AZspftLSB <br /> IaHONE �(Q FAGSIT�Ari fe . f P ' '71l.Z <br /> TrENTATNE0 APPO mnmNT DA-m 1AE <br /> (Plsa�6e give 7 9WMU <br /> xtate n;Z;1ttal) <br /> Wr <br /> CHECK BQA TO EXPEWE REQt F_ST- 9.Q0 FEE Eadl AMC <br /> ES, D AY5 <br /> SIGNATURE OF APPLICANT >�' � GATE �l(L72. <br /> FILE AbV SS TNtS SIRE I0 AFF UR Y <br /> PROGOAR EPEMEtM SEAKCH <br /> Sas !�1 k-Ile S•�-4 <br /> V <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> l UNDERGROUND TANK-(UST)CLEANUP SRE(LOP) C3 H09JSING AUATEMENT Ca SOUL)WASTE FACILITY <br /> ❑ OTHER CLEANUP SlTR tNON-LOP) 13 FOOD FACILITY 11 SXID WASTE VEIX" <br /> 0 UNDFRrPROUND TANK(MQf4 TORINQ199NQVAL) C3 opt;KENNEL C1 DAIRY <br /> Irl HA7_Alt00133WAST'I:0E!{EMTaR E3 CHICKEN RMGH G PIC6TREXWEA1TPLANT <br /> M meRED PER1AtniEu FAEaLrry E3 MOTELIHO-ML ' 0 P"PEA TFMCWYARRII MCM TOILETS <br /> n TATTOOMODY PE3RCING Cl POOLISFA, E3 LAN13 MIE APPLIGATfON SITE$ <br /> M f"IGAL WAM FACILITY iD PUBLIC WATER SYSTEM 0 CIrT'#IER(PLEASE SPECIFY ABOVE) <br /> h. List up to ton addresses in the space above, Sek-ct the type(s)of 11189 from the Itst above by ohacking <br /> the appropriate box(v4 At lea;t one file typo MUST'be selected. Fax to 21x9 738 r mail e <br /> address indicated Ahm, <br /> i 2- EHD will notify th©applicant if any END files exist An appointment for review will be confirmed <br /> approximataly five bur-Inces days but no latar than ion(10)drys after receipt of application. The fllas <br /> will be Held fora maximum of five business days for review- Appointments should be sl:HetlLded <br /> accord'In$ly.• - <br /> 3. A fi#e that Is gptivety being workedan by FltD Staff may 1lOt be immediately avallable Tor revlow. A now <br /> applICAtion Inay.110 Supntitt d When the file is available. " <br /> 4. Any Elle riot retUMcd in the salne condition deg released will be reorganized by EHD staff at the expense <br /> of the applicant. Future file reviews by the same applicant may requires?$80.00 deposit priar to raivlow. <br /> b. 'TENTATIVE AP99intrnont cMtes must be confirmed with EHO staff. <br /> B. AppRcations reGCivsd after 3:00 prn will be processed the next Business ddy. <br /> CONFAB IED APPOINTMENT GATE _ � ._ 'T04E <br /> DATES CONFIRMED _. -.-- PHONS FAX INITIALS _ <br />{. REEVIMED YFS N4 REVIEW DATE <br /> rs +z s►� <br />