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r �j(& <br /> SAN J V At j UIN COUNTY IL-IL <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PURMC RECORDS RELEASE APPLICATION <br /> APPIICANT �G� Q c_ ! ONS NO �Sio��2o <br /> ADDR.9SS_,t,2r G c, ler avt �6 <br /> AC,ENCY NAME "/4 {aJrr C liy" pn S v n PHONE NO S< tc f <br /> ADDRMS Sq�vcP <br /> PSI �DRFisS ��# ��.GBCLC�X p <br /> 7e . �{Dr��tr7 3 S•3o S S <br /> o //Ya�/rc�S " tiryg , 1_.VJ: , y Sfl1Jn 3.57 <br /> o,aJ ./c,nS�Ta o r 4lx Ef -37 S S <br /> o� l ,� ZZ �Yliar� lcefi E 3�• a'1 /11-�'�l - — <br /> o C7reyltDpck&r1__35, rlk, <br /> - <br /> L <br /> AYco, 2�5- N. - <br /> '-IHS NCrnCE IS SUBJFiCI TO '11113 REQUIRHMHNTS IDEIMFIED IN THE PUBLIC UP-M,111 <br /> SI3LVICE91E'4VLRO'IMENTALIIEiLTHDIVISION(MID)POTICY 02-001,ORDINANCE CODE OF SAN <br /> .T0AgM COUNTY, MID PERS AND SERVICE CHARGE RESOLUTIONS, MkTE WATER COD$, <br /> OOVERNMENT CODE AND THE EVIDENCE CODE. <br /> 1- A MAXIMUM OF TEN (W)PREMISE ADDRESSES PER REQUE.-T. <br /> 2. PUBLIC 1ILE.SMEC.ORDS "MIRW. .ARR BY att2IN'P_HfiNTONLY. APPOINTMENTS ARR <br /> APPANGPD BY CALLING C2(19)468-0M0, OMCE ITOURS FOR APPOLNTMENIS ARE SCHEDULED <br /> MONDAY THRU FRIDAY EXCLUDING HOLIDAYS, 8:00 A.M.T) 12:00 NOON AND 1110 PAL TO 4:30 <br /> P--M. <br /> 3. A PUBLIC RECORDS RELEASE APPLICATION AND A XQff-{Z&I�[[p�B[2 DBF(),Sl'I'OF S78.W <br /> 1S REQUIRED. DEPOSITS WILL BE RETURNED TO THE APPLICANT IF TIM MZWRECORDS ARE <br /> NOT AVAILABLE WTT RK TIM CTI.'4T0DY OF THE E ID. <br /> #. THE ABOVE IDENTIFIED DEPOSIT IS APPLIED TOWARDS THE TOTAL FILE RBVIRW PEH <br /> CHARGE. THE BALANCE OF TIM CHARGES ARB DUE AND PAYABLEgRi(�T)REVIEWING TILE <br /> DOCUA ENT(S)- <br /> .5. PUBLIC FILESlRECORDS NOT REnTtNED IN THE SAME CONDITION AS RGCEIVED WILL FH <br /> CORRECTED By TRE PHY) STAFF AT THE EXPENSE OF THE APT'r_ICANI'. '1TLT3 ADDITTONAI. <br /> SRRVICIF WILL B6 BILLED TO THE APPLICANT FOR PAYMENT, <br /> A. OPIOINAL PUBLIC ITLESIRECORDS SHALL NOT BE REMOVED MUM 'THE ERD PRENaSES. <br /> SIGNATURE OF APPLICANT "% —DATE Z �v <br /> SIGNATURE OF PH—RASLK?- OFFICIAL DATE - <br /> rJl OO 14 (REV 12.19)-) <br /> �lpu� \�, <br /> /Nu <br />