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PHONE NO. - 209 369 4228 k _. FebUJ ZrieM VJr <br /> !! 1 <br /> ] r OLmmumack <br /> SATE u' QUIN COUNTYPUBLiC H .I.TH SE13VICES j <br /> ENVIRONMEWAL HEALTH DIVISION <br /> 304 FAST WEMR AVEMU> .THIRD FLOOR <br /> STOGnON Cit M= <br /> i` (203)40-34202a <br /> PUBLIC R <br /> CORDS RELEASE APPLIC6�TION <br /> A7'�Llft= altSitlE_slArlY �. <br /> Amoss 2 � <br /> AFtOHir — FAC9fA!U G ^ 2 <br /> TEIN'TATIVE•APP' urmEHT oATE f <br /> F <br /> 4FIease pllvg T to 10!luslnesa days lram�o!appl'RstJaR�Ntt+uetal) <br /> C1tE0K BOX YO tJCPRDI7�r2sCivaT-41�.4n FPS_ftEGA1EST BROGESSFA 1H 3 94l&WFS a PAYS <br /> SIGNATURE OF APPLICANT &ryl DATE <br /> .F <br /> F"ADD RM <br /> 7 - �rM <br /> _1U 1C(0 <br /> Fr115bt <br /> ii <br /> ENVIRONMENTAL HEALTH GIVISIONfFILES <br /> 1 ) i-UNnF-RgE oumb TAoax tusT)cigAmp srrF(LOP) HOUSING ASAWMENT R C3 5O tDWASTE FACILITT <br /> M 0TM GL EANtiP ra M tHOH4.OPI ❑ FOOD FACILM (-"3 I40:.10 N[AM VENICLZ <br /> UMMr- OMO TAi1K(1SAHIT[1lL�ilKlw&MA14 Cl WGX1zMN" k ❑ iWity <br /> F1A?ARDfl W 11 f�7H� A'roR M CiEVXU4 RAMR 13 AISQ T A17ktW PLANT <br /> C I!ilytL'A!'t AffT1:D FAGILI:Y CI MOTFLmom % ❑ plfl�F•iZ TRUCMAR=HEI TOII QTS <br /> T <br /> 0 ' MMOOY PtthLING 13 POOLWA ❑ lE1r�fIS F-APPLICATAN WMS <br /> { M YE10MALWA$n rACLITY a PURUC WATER SYSTEM C3 6TWR(RX-ARE SPECWY ABOVE) <br /> 1. List up to tvn ad0rec4aa in the apace abmm. Saiact the tyWs)of flies Moms the fist above by checking <br /> the appmpriate box(va). At least onv Ella type MUST be eei*ctad- 8 the <br /> � ���� it7diaated sbgy� '' <br /> 2. SkD w0l notity the applicant it any END files wdst. An appointinant for renew will de tan$irmed <br /> approxlttlately free bu sisoss dayr but no tutor than tan(10)days aftwj`reccipt of application. Tha!Iles <br /> will bo hOd for a rnaximt+rrt crf five business days for review. Appolnth"ts ahouid be saheduled <br /> � art;a�rl!>tigiy_ it <br /> 3. A rile that is acovoiy being warlrad an by Eli❑staff may not tea'4 mec5ateiy avaflab4a for roviaw. A new <br /> apAllration May be subrnittrd when the flia Is avatiabla. <br /> 4. Any Me Hot returned in the Cams candMan as rpleascd will be reoiDa'ntwo by EHD staff-at the s:penae <br /> i of the eppiieAnt. Future file reviews by tare sauna applicant may require a S7a.00 deposit prior to raoew. <br /> 1 5. 'TENT'At i IVE appolntrment slates must be confirmed with EHO stttTf. <br /> 6. Applications reosfYed attar 3:04 pm wi11 be processes(tate next business day. <br /> 31 'I <br /> CONFIRMED APPOINTMENT DATE T1M� <br /> OATECONFIRI F-0 ..._ PHONE FAX IMMALS <br /> RE14I11WED YES NO REVIEW 13ATE <br /> 14 Cay <br /> TOTAL P.as <br /> gib:: <br />