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PUBLIC HEALTH SERVICES q <br /> &-yvM0NNj MNTAL HEALTH DIVISION �� Report 15021 <br /> PUBLIC RLI <br /> RECORDS RELEASE APPCATION ----- -----___ <br /> K LE 1 NF EC_Q>EiR j TNG • -actions in RED pen or pencil <br /> APPLICANT t TON rv114R-'r- PHONE NO 7x09 - 9�S /3�}S ;E (date)• <br /> 16ADDRESS ZRJ ZS Tl_.E STDGK•Tt`�N G'► 9 5-Zos' (date): <br /> AGENCY NAME PHONE NO <br /> ADDRESSFrL ` <br /> 1 <br /> E ADDR.FSS LEAD AGENCY DATE <br /> p{L v S �e.5Ti4K <br /> 2�nIT nt IUJ O <br /> C 2A <br /> • k <br /> ' THIS NOTICE IS SUBJECT TO THE REQUIREMENTS IDENTIFIED IN THE PUBLIC HEALTH <br /> SFgVICEVENVIRONN ENTAL HEALTH DMSION(EHD) POLICY#94 007, ORDINANCE CODE OF SAN <br /> JOAQUIN COUNTY. EHD FEES AND SERVICE CHARGE RESOLUTIONS, STATE WATER CODE, <br /> GOVERNMENT CODE AND THE EVIDENCE CODE <br /> ' 1. A MAXIMUM OF TEN(10) PREMISE ADDRESSES PFA REQUEST. <br /> 2. PUBLIC FILES/RECORDS REVIEW IS BY &MrNTMEM ONLY APPOINrMUM ARE ARRANGED BY <br /> CALLING (209)468-0340 OFHCE HOURS FOR APPOINCI Ms ARE SCHRDLILED MONDAY THRU FRIDAY <br /> ExcLuDwa HOLIDAYS, 8:00 AM TO 12-00 NOON AND 100 PM To 4 30 PM. / Facility / ACCOU' <br /> cle one) <br /> 3. A PUBLIC RECORDS RELEASE APPLICATION (PRRA) IS REQUIRED (circle one) <br /> ' —Activate / ----^--- <br /> 4 Pvauc FILFS/RECORDS NOT RETURNED IN THE SAME CONDITION As RECEIVED WILL BE CORRECTED Delet <br /> BY THE EHD STAFF AT THE EXPENSE OF TILE APPLICANT THIS ADDITIONAL SERVICE WELL BE B1II FD TO THE - <br /> APPLICANT FOR PAYMENT (SEE EHD POLICY 94-007) _�—.. A —� D ---_�—. <br /> 5 <br /> ORIGINAL PUBLIC O NOT BE VED FROM THE EHD PREMISES edge that alt site and/or <br /> _ q he party identified as the <br /> SIGNATURE OF APPLICANT DATE i ilI applic�le 5A11 doAoljlM <br /> SIGNATURE OF RELEASING OFFT DATE• it------------------ <br /> -No <br /> --- --- / --1--- <br /> NO PHS/II1D RECORDS/FILES ARE IDENTWMD Date <br /> CAM asvmww ar FinVWAnas DAM Date ' <br /> Recvd by <br /> ,HsjEH D REcoRDS/FD.BS EXIST ON THE ADDRESS(ES) NOTED YOU WILL BE NOTH= WHEN =m0smu ssiasasmmass===1t <br /> ECORDS/FILES ARE AVAILABLE FOR REVIEW. � UNIT/File' ' �� <br /> 1. Rremww ar rimww_.nC"MTm <br />