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1 <br /> SAN JOAQUIN Csfr' <br /> / ( PUBLIC HEALTH SERVICES <br /> IENVIROIr'I�4ENTAL HEALTH DIVISION �j I9�B <br /> P'GBLIC x CO S RELEASE APPLICATION <br /> RRppersan <br /> uzah e4�dI1 // <br /> /APPLICANT 0. 2 I On M PHONE NO'— <br /> ADDRESS I 50 CK-1—OA.) GA Q ri Q Q3 <br /> AGENCY NAI`f _PHON'E NO <br /> ADDRESS <br /> F ILB ADDRL•SS LEAD AGENCY DATE <br /> 1 r7I In n - U S0�_ <br /> -1 00'7 <br /> aa1 1 <br /> lLoa <br /> voo ar<1 UPiA <br /> TRIS NOTICE IS SUBJECT TO THE REQUIREMENTS IDENTIFIED IN THE PUBLIC HEALTH <br /> SERVICES/ENVIRONI.IENTAL HEALTH DIVISION (EHD) POLICY 6'92-007, ORDINANCE CODE OF SAN <br /> JOAQUIN COUNTY, EHD FEES AND SERVICE CHARGE RESOLUTIONS. STATE- NATER CODE, <br /> GOVERNMENT CODE AND THE EVIDENCE CODE. <br /> I. A MA\7MUNI OF TEN (10) PREMISE ADDRESSES PER REQUEST. <br /> r <br /> 2. PUBLIC FILES/RECORDS REVIEW ARE BY APPOINTMENT ONLY. APPOINTMENTS ARE <br /> ARRANGED BY CALLING (209)468-0340. OFFICES 14OURS FOR APPOIN MFNTS ARE SC14EDULE•D <br /> MONDAY THRU FRIDAY EXCLUDING HOLIDAYS, 8:00 A.M. TO 12:00 NOON AND 1:00 P.M. TO 4:30 <br /> P.M. <br /> 3. A PUBLIC RECORDS ULEASE APPLICATION AND A NON-REFUNDABLE DEPOSIT OF 578.00 <br /> IS REQUIRED. DEPOSITS RILL BE RETURNED TO T14E APPLICANT IF THE FILES/RECORDS ARE <br /> NOT AVAILABLE WITHIN T)iE CUSTODY OF THE EHD. <br /> 4. THE ABOVE IDENTIFIED DEPOSIT IS APPLIED TOWARDS THE TOTAL FILL- REVIEW FEE <br /> CHARGE. THE BALANCE OF THE- CHARGES ARE DUE AND PAYABLE PRIOR TO REVIEWING THE <br /> DOCUMENT(S). <br /> 5. PUBLIC FILES/RE-CORDS NOT RETURNED IN THE- SAME CONDITION AS RECEIVED RTLL BE <br /> CORRECTED BY THE EHD STAFF AT THE EXPENSE OF THE APPLICANT. THIS ADDITIONAL <br /> SERVICE RILL BE BILLED TO THE APPLICANT FOR PATIENT. <br /> 6. ORIGINAL PUBLIC FILES/RECORDS SHALL NOT BE REMOVED FROM THE EHD PPL 'flSES. <br /> SIGNATURE OF APPLICANT — DATE <br /> SIGNATURE OF RELEASING OFRICiAL DATE <br /> F}1 00 14 (REV 12/97.) <br />