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lrrLo zr:EJ ie-•Zk:J'T1 t-Kt TO LJG ,d'ji'�tr4H i-, <br /> G1i_iii:tiEtLGQ VCU lVli NUMtltI( <br /> AQUIN COUNTYPUBLIC HEALTH S, <br /> RE <br /> CSN <br /> D SAN -� ENVIRONMENTAL HEALTH DIVISION -,rlc�3 ` <br /> 304 EAST WEBER AVIENUE,THIRD FLOOR <br /> QCT 1 6 2000 STOCKTON LA 93202 <br /> (209)468-3420 <br /> EN ONNIENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> PP <br /> PrL1GANT C = n 1�USINEfS�S�AG�ENCCJY <br /> ADDRESS <br /> PHONE fQ 3 —q FACSlIALE <br /> TENTATIVE`APPOINTMLISri DATE- &Q T.I. na All <br /> (Please give 7 to 10 business days from date of appacation submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-567.00 FEE-RIr40UE9T PROCE95ED IN 3 BUSINE5S DAYS J <br /> SIGNATURE OF APPLICANT PATE ��f l'j l �`� <br /> FILA AOPRES9 THIS SIDE CHO STAFF USE ONLY <br /> PftOGKAM tcLUMf.KTS SEARCH <br /> ?—b n t S <br /> ENViRONMLNTAL HEALTH DMSION VILF. S <br /> 11NC1kp.GROUND IANiK(UST)CLEANUP SITE(LOPj CI NOU5LNG ASATEMeN7 ❑ SOLID WASTE FACILITY <br /> TftF GLEANUP SITE(NON-IIOPi ❑ FOOD FACILfTY InSOLID WAST£VEHICLE <br /> NMRGROUNO TANK(MONITORINGIREMOVAO ❑ DOG KENWEL CIOAU Y <br /> XHAZARDOUS WASTE GENERATOR In CHICKEN RANCH t7 PKG TREATMENT PLANT <br /> RED PERh11TTED FACILITY C3 tAOTEUHOTt:L 0 PUMPER TRUCIUYARMCHEPA TOULT <br /> p TIE <br /> O TATTOOMODY PEIRCWG Cl OOUSPA ❑ LA'iD IISEAPPLICATION A5O <br /> XMEDICAL WASTE FACILITY PUBLIC WATER SYSTEM O OTHER(PLEASE SPECIFY y the <br /> 1. LI$t up to tort addrt>•sses in the space above. Select the type(S) of files from the list above by ohit tp h¢g <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(209)464-01 18�Lfn,� <br /> address indicateI above. <br /> 2. €HA will notify the applicant if any EHD files exist An appointment tar review will be wnfirmed <br /> approximately Five business days but no later than ten (10)days after receipt of application►.-The files <br /> Will be held for a maximum of five business days for review. Appointments should be scheduled <br /> accordingiy. <br /> �. A file that is actively being worked on by EHD staff may not be immedlatety aYailable for review. Anew <br /> application may be submitted when the file is available. <br /> 4, Any file not returned in the same condition as released wlil be reorganized by EHL) shaft At the expense <br /> of the applicant. Future fife reviews by the same applicant may require a$87.00 depuait prior to review, <br /> S. *TENTATIVE appointment dates must be confirmed with EHD staff_ <br /> 6. Applications received after 3:00 pm will be processed the next busine55 day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> hEVIEMD YES NO REVIEW DATE <br /> �ro 14 oD+17 TOTAL P.02 <br />