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SAN J- WIN COUNTYPUBLIG HEALTH SER` LU <br /> . .WIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBFR AVENUE, THIRD FLOOR <br /> STOCUON CA 95202 <br /> (209)468-3420 <br /> 1, PUBLIC RECORDS RELEASE APPLICATION <br /> APPMANTI KkmkA�'l- MsL4VE9�, 6UcS+INESSIAG£NCT Cojyt�. KTZ+r I� }{.N oLoG76S <br /> ADDRESS t� NYL WL;ST CtFu-t+`�' Ju\' •L. STt3 GI�Tb N . —4 <br /> ?HOME 2 3y oSl p. C44MILEor38 <br /> TENTATIVE"APPOINTMENT DATE TIMF <br /> (Pleax 91vet7 10 T D bmltteas deYs h0m Beta of appllcJ1t!W SUbMRIeq <br /> I] CHECK BOX TO EXPEDITE REQVLS <br /> (-11,117:5 <br /> EQU�PROCE3�D UI J BUSW"S DAYS <br /> OCT 1 s <br /> SIGNATURE OF APPLICANT —- DATE o r B 0 <br /> FILE ADDRESS THIS WE EHD 5TAFF UU ONLY <br /> PROGRAM ELEMENTS SEARCH O <br /> cA 07 5;-3FL <br /> oW. FiF S . <br /> — r <br /> 20 <br /> z. S_ <br /> ISs f2oAT14 LT. <br /> 2 0 --�VJT � v�/�` <br /> 4 CI <br /> ENVIRONMENTAL HEALTH DtV1510N FILES <br /> r UNDGROROUND TANK(UST)CLEANUP SITE(LOP) 0 HOUSING ABATEMENT X SOLID WASTL FACIUTY <br /> X OTHER CLEANQP%T9(NON-LOP) ❑ FOOD FACILITY O SGLID WASTE VEHICLE <br /> Al UNDERDROUNOTANK(MONITOKR#oI EMOYAL) 0 PPI(i KENNEL powwy <br /> A HAZARDOUS WASTE OCNCRATOR �GHIGKEN RANCH O PKO TREATMENT PLANT <br /> ITY CJ <br /> 0 TIERED PERMITTED FAC-LMOTEUHOTEL 0 PUF%P=R TRUCK(YARW'CHEM TOILETS <br /> ❑ TATTDOiSOOYPEIRCWG A POOWPA - 0 LANO USEAPFLICATION SITES <br /> pr-MEDICALWASTEFACILn 0 PUBLIC WATER SYSTEM 0 OTNER(PLLASESPECIFYASDVE) <br /> 1, List up to ten addressor In the space ahove. Select the types)of files from the Its:above by checking <br /> the appropriate box(es), At least one file type MUST be Selected, Fax to(9081464:0138 or mail to the <br /> address indicated„ bR oyo- <br /> 2. EHD will notify the applicant it any EHD files exist. An appointment for revlaw will be confirmed <br /> approxlmataly five business days but no later than ten(10) days after receipt of application. The files <br /> Will be held f0r a maximum of five business days for review. AppOintmants should be Scheduled <br /> accordingly. <br /> 3. A file that is actively being Worked on by END staff may not be immediately available fat review. A new <br /> appllcption may be submitted when the Ilia Is avallable, <br /> 4. Any file net returned in the same Condition as released will be reorganized by EHD staff at the expense <br /> of the applicant. Futbre file review$by the Same applicant may require 2$97-00 deposit prior to review. <br /> 5. 'TENTATIVE appointment(10105 MUzt be COnfirnled with EHD staff. <br /> 5, ApRUcallons received after 3:00 pm will be processed the next burinas5 day, <br /> FGONFIRMED APPOINTMENT DATE TIME <br /> DATECONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEWDATE <br /> LH ao ro�w <br /> TEFL P.32 <br />