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!L � lU ! A�CJNp.?CC`)JJ r.L1 <br /> SAP! JQ!C.2UIN COUNTYPUBLIC HEALTH SEt7110ES <br /> ENVIRONMENTAL HEALTH DIVISIONFLOOR <br /> 304 EAST WEBER AVHN[lE,THIRD FLOOR <br /> STOCKTON GA 03202 <br /> (209)468=3420 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> ApPucANr_ 1L'�1�(iv� 1�-�Q t-j�1'1 susuvtssAG�Ncv1�� Arroc .�er� --- <br /> ADDRESS �^ ' 1 <br /> FACsiwLE 41 p �j — '� • <br /> TENTATIVE"APPOINTMENTDATEL D� <br /> -- - TIME _Lr <r/fadry <br /> (pl®a'.a Sgva 7 t0 P b noes days from data of appticallon su4rrdttaq <br /> CHEGK BOX TO tL16'ED1TE RPgUE$T-Sb7� QU PRCCE$$ED IN 313USINESS DAY$ <br /> SIGNATURE OF APPLICANT L DATE <br /> FILE ADpRF.SS TNIS SIDE END STAFF USE ONLY <br /> f�OAO tr,�t: PROGRAM ETS LEMENSEARCH.1'L<cc/nary <br /> OS'//1!e/✓ ah lL�cck Lx oqc <br /> X✓ S PJ hero ce a ./`&pc/reory 2 Z. 30 <br /> IfoRl� <br /> a .. aG%25o� �- <br /> �� aN$on Dai! .r�ac tqa � <br /> � n <br /> it <br /> ENVIRONMLNTAL HEALTH DIVISION FILESUT <br /> UNDERGROUND TANK(UST)CLEANUP SITE(Lop) M HOUSING:A(dATEMENTA <br /> 'OTHER CLEANUP SRM(NON-LOP) ❑ FOOD FAC11.tTY 0 SOLID WASTE PAIA= ' v <br /> 6XVNDEAGRUUNDTANK(MOHITORING?2EMOVAL) <br /> C3 DOG SOUDWASTEVEHICLE <br /> HAZARDOUS WASTE GENERATOR ❑ <br /> Y <br /> C3 TIGRED P£RwrrED FACLLrry CHUCKEN RANCH p pKG <br /> TMErr PLANT <br /> 13 TATTOOrRODY PERCINO M TFL 7PUMPR TRUCWYARntGH <br /> [M 7 <br /> OILe sO MEDICAL W"T6 FACILTY D POOU9PA EI LAND USE APPLICATION SRESQ <br /> PUSUC WATER SYSTEM 4 OTHER IPLF,&SF gp[{IFy A0QVF <br /> List up to ten addresses in the space above <br /> add Select the type(s) of filar from the list above by chocking <br /> the appropriate box(es). At least one file type MUST be sele<tetl. Fax in !2091415541a'3 738 or mall to the <br /> s 'ndicatedabov <br /> 2. EHD will notify the applicant If any EHD files exist. Aa 2PPof+trnent for reviaVv will be confirmed <br /> wil <br /> approximately flue business days Out no (afar than ten(10)days after receipt of application. The files <br /> l be held for a maximum of five business daySfor review. Appointments should be scheduled <br /> accordingly. 14, <br /> 3• A file that is actively being worked on by EHD s <br /> Is 1j, efab not be immediately available for reriew. A neer <br /> apPECation may be submitted when the file I <br /> 4. Any fits not returned in the same condition as rely <br /> of the appliieant Fixture file reviaws b the as axed will be reorganized by EHD staff of this expense <br /> 6. •TEtVTATIVE a y 1 �PPiiCant may repUire a 597.00 deposit prior to review. <br /> 6. Ppaintmant datet.tnusL be cottfjRii d with F"D staff. <br /> Applications received after 3:00 pm will be Pro¢wis•d the next business day. <br /> PONFIRMED APPOINTMENT DATE TtlVB <br /> DATE CONFIRMED <br /> i P40NE FAX INITIALS <br /> REVIELYED YES NO <br /> 6M 79 H QM7W .'°,1. REVIEW DATE <br /> `. .TUTFt_ P.al <br />