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I :,WAhI FRP" AGE NC 209 9S6 0700 P. 1 <br /> SA �r <br /> N' J aQUIN COUNTY <br /> LT„ PUBLIC HEALTH SrRVLCEs ( ( 7 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> II3LIC RECORDS RELEASE APPLICATION <br /> APPLICANTgffcLA.,M Lfe F ,..r,n.r..n+nl — T Catl�tBVtiONNO 5 4 o a 6y <br /> ADDRESS_L�D3_W. MAA,ki LgmL- C-}f. A x`54% K�'.A _ <br /> AGENCY NAIv[H PHONE NO <br /> ADDRESS <br /> FILE ADDRESS 1 LEAD ACEnN'Cty DATH <br /> 5950 s•_ELD.Ah& aicm-)'.SJuL*6a <br /> "76nfill <br /> Ind..st�;nl 4�r� C <br /> 45o E L J„5+r;�1 aAirt <br /> -- <br /> �43 7 S. AtCPer -vnT�{ <br /> TRIS NOTICE IS SUBJECT TO THE REQUIREMENTS IDENTIFIED IN "IIIE PUBLIC HEALTH <br /> SERVLCES/ENVIRONMENTAL HEALTH DIVISION(PHO) POLICY"2-007. ORDINANCE CODE OF SAN <br /> JOAQUID' ^^ ” ^ �^ c ,,... .,.�.: ,..„��E RESOLUTIONS. STATE WATER CODE, <br /> GOVERN <br /> 1. A 1 I LIiJ J en t 112 vy , PER REQUEST. <br /> 2. P CLIZ (.) )I�T'MENT ONLY. APPOINTMENTS ARE <br /> ARRANCf S FOR APPOINTMENTS ARE SCHEDULED <br /> O U <br /> DA' PC�� __II CL M. TO 12:00 NOON AND 1:00 P.M. TO 4:30 <br /> P. <br /> 3. P YL'n 1 11 C _ )A NON-REFLINDABI.E DEPOSIT OF S7S.00 <br /> 1S REQU: APPLICANT IF THE f•ILFS/RECORDS ARE <br /> NOT AVi <br /> 1"/12 t� CP S-D--'A5 <br /> 4. 7 'O WARDS THE TOl'Af. FILE REVIEW FEE <br /> CHARGE ND PAYABLE PIUOR TO REVIEWING THE <br /> U(H,UMJ <br /> 5. P LL tzp-- SAME CONDITION AS RECEIVED WILL BE <br /> CORREC IF THE APPLICANT. THIS ADDInONAL <br /> SERVICE WILL, BE BILLED TO THE APPLICANT FOR PAYMENT. <br /> 6. ORIGINAL PUBLIC FIIESIRECORDS SHALL NOT BE REMOVED FROM THE EHD PRFMISES. <br /> SIGNATURE OF APPLICANT DATE 3 g <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> Ll W 14 (REV 12192) <br />