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SALT joAouiN coumr ' <br /> JILMLIC HEALTH SERVICES <br /> F,j,miQNT'IEN I AL IIEAL'1 II DIVISION `a <br /> PUBLIC RECOH.US RELEASE AYPLICATIOjt lr, .r <br /> � 14 <br /> APPLICANT PHONE E�v� <br /> N11� <br /> ADDRESS PH�NI3 N �SEf LTN <br /> AGENCY NAME �fSJrs �1� �f3 <br /> ADDRESS <br /> i3 GU= <br /> f �w <br /> ' I'kllS I+iu1"1CF: [S SIJBJE:GT I'O Till: RLiQUIRENIENTS 1DENT1F1(:I) IN '1'Ill= PUBl.IE: IiEALTIi <br /> StrRVlcteS/rNVIR(NJt�i1:N,rA(.11LAl=rli DIVISION Mill))"olJ('Y 4921107,()RC)1I*AI'ENANCH ATECODC SAN <br /> JOAQUIN COUNTY, 1:110 FEES AND SERVICE CHARGE RESOLITI'IONS. s PATE WATER CODH. <br /> 1}OVERNMENT CODS AND TFIB EVIDENCH CODE. <br /> I <br /> I, A MAXIMUM OF TLN(10) PRirSilS13 ADDRESSES PER REQUEST. <br /> 2. ('lJ1i[1C 1't[1•S/ltii(v()Ri)S RLVIt-W ARE HY APPOIIIJ`.:1MI�NT (�N1.Y. r�t'1'nlNThiLNTS ARE <br /> ' <br /> ARRANGED 13Y CAi.tlNE3 (?()9)4684)3-10. t)t li('13 llnt-JRS t�OR APPOINTNIENTS Alii: SCt1EUVI.I=n <br /> 1 MONDAY THRU PR►nAY EXCLUDING' 11OL.IDAYS. a:00 A.M. TO 12_00 NOON AND 1:110 P.M. TO A:30 <br /> P.M. <br /> 3, A PU13L_jC R1?C'E)RDS RELEASEAP111CA'11ON ANI.)A Nn RL'I'1tN13A131.1:DFP(1Si't'(�F �78.U0 <br /> IS KI311UIR1:1). DEPOSITS WILL Bt3 i2LIUliN1_D"i'() 11I13 APPLICANT 11' 1-116 FUJiSIRECORDS ARL? <br /> NOT AVAII-ABLE W11111N "113 CUSTODY OFTHE HIID' <br /> q• •111 Alt0V6 lI)EN'Tll;1i-1) DEPOSIT IS APPI_103 TOWARDS -n11= ' rAL FILL REViCW PEE <br /> CHARGE. '111133 BAI.ANCII OI' '1116 CHARUES ARE VUH AND PAYABLE 11100 _I'U REV11iW1NG TILE <br /> I <br /> DOCUMENT(S). <br /> S. Pl1BI 1C' HLESIRF-C ORDS NOT R&111RNED IN TFIE SANTE CC1NI)1'f ION AS RECEIVED WELL B>: <br /> CC)RRECII±U BY 71113 CFIU STAFF AT 71I(r EXPENSE OF TILE APYI ICANT. THIS ADDrIlONAL <br /> SERVICE WILL BE BILL$[ TO THE APPUCAN f FOR PAYMENT. <br /> 6, ORIGINAL PUBLIC FILl:SJR.irCORDS SHALL NUT BC REMOVED FROM THE 01U PREMISES_ <br /> SIGNATURE OF APPLICANT DATE ^l <br /> SIGNATURE OF RELEASING OFFICIAL LATE <br /> Ell 00 la M..6V 12192} <br /> / /y <br />