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1 t13 I�r+6 1 I =.14rP1 FFWr l AGE NC 269 SS6 0700 P. I <br /> SAN Jp <br /> UIN COUNTY JJ�� l l lJ <br /> T.. PUBLIC HEALTH SERVICES ( p� <br /> ENVMONIVIINTAL HEALTH DIVISION <br /> SSI IC RECORDS RELEASE APPLICATION <br /> APPLICANT 14d.,a..vn lF . --:�.,+nl – T C Qll.h'HONL NO q-S 4 0 bel <br /> ADDRESS_1 ,3_ <br /> AGENCY E NO <br /> ADDRESS <br /> MIJE ADDRESS LEAD AGENCY. DATE <br /> 14.301 <br /> 76n h.qs.z Al we <br /> loco <br /> IAA x{�lol !lr C <br /> .13ZIS1_�s.�ti -A S1-rc i- l <br /> 143'7 5. AjryaN' -wn� , <br /> — <br /> y+io'7 <br /> 4iq1_7_ '7 Fl � Jln ae Si levL <br /> T1iIS NOTICE IS SUBJECT TO THE REQUIREMENTS IDENTIFIED IN '114E PUBLIC HEALTH <br /> SERVICES/ENVIRONMENTAL HEALTH DIVISION(FHD)POLICY X92-007,ORDINANCE CODE OF SAN <br /> IOAQUIr RESOLUTIONS. STATE WATER CODE. <br /> GOVERN <br /> I. A I I�liJ Jen tIeIti, (L PER REQUEST. <br /> 2. p �LIG)�-, I1C1 5 C� )INTMENT ONLY. APPOINTMENTS ARE <br /> ARRANG S FOR APPOINTMENTS ARE SCHEDULED <br /> MONDA' M. TO 12:00 NOON AND 1:00 P.M. TO 4:30 <br /> P.bL reC��, ,L xit7-6 <br /> 3. A ��'Yl c�11�C I A NON-R EFIJN DABLE DEPOSIT OF$78.00 <br /> IS RRQU: I APPLICANT IF THE 11LESIRECORDS ARE <br /> NOT A I'Ai2 � Cl s-,�LA� <br /> �. 7 7 I 'OWARDS THE TO'1'AI. FILE REVIEW FEE <br /> CHARGE ,ND PAYABLE PIUOR TO REVIEWING TILE <br /> UUCUMI <br /> 5. p SAME CONDITION AS RECEIVED WILL BE <br /> CORREC JF THE APPLICANT. THIS ADDITIONAL <br /> SERVICE WILL BE BILLED TO TIIE APPLICANT FOR PAYMENT_ <br /> 6. ORIGINAL PUBLIC FILES/RECORDS SHALL NOT BE REMOVED FROM THE QM PREMISES. <br /> SIGNATURE OF APPLICANT Q4 aaDATE113) <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> LI 00 14 (MV 12!92) <br />