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-%� L'ID LC-. <br /> DXTEREatt4ED SAN ,)l 'aUIN COUNTYPUBLIC HEALTH S( 110ES <br /> N tl , ME <br /> 304 VASIROTJWEBERAvENUALTHIRDI FLOIOR� �pt� <br /> OtV , I STOCKT GA 95202 <br /> 46 <br /> (204)d68-3420 / T <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> BUSINESS/AGENCY sU_wn <br /> APPUCAN Q liy.yl ti s <br /> ADDRESS 83 <br /> 7n(x (,//nn ����� FACSIMILE <br /> PHONE �jTIME :dd 4 2001 <br /> TENTATIVE`APPOINTMLNT DATE. <br /> (Please glue 7 to o�Ibu/alna d)(a'ys m date/o7f/`apPlip tlm+sunmltta <br /> U' ` l/` pR�SSEO W 3 BUSINESS DAYS <br /> LDL CHECK BOX TO EXPEDITE READ 78.00 FEE-REQ DATE /1 <br /> SIGNATURE OF APPLICANT (/ <br /> FILE ADDRESS <br /> RF � . 0 <br /> TyF a_ sr c_elar 7� t <br /> Cus7" � <br /> NFI S <br /> Lf I S <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT 0 SOLID WASTE FACILITY <br /> ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> OTHER GROUND SITE(NON-LOQ ❑ DAIRY <br /> UNDERGROUND TANK GENERATOR <br /> RINGIREMOVAL} ❑ DOG KENNEL ❑ FKG TREATMENT PLANT <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH <br /> TIERED PERMITTED FACILITY CINOTEUHOTEL ❑ PUMPER 7RUGKlCATION*tM TOILETS <br /> ❑ TATTOOfBODY PEIRCING In POOUSPA ❑ LAND USE APPLICATION StrES <br /> Cl NEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1. List up to ten addresses in tile space above. Select the type(s)of riles from the list above by Checking <br /> the appropriate I)OX(es). At least one file type MUST be selected. FaX to (209)464-0138 or mail to the <br /> address indi ated above. <br /> 2. EHD will notify the applicant if any EHD riles exist An appointment for review will be confirmed <br /> approximately five business days but no later than ten (10) days after receipt of application. The files <br /> will be held for a maximum of five business days for review. Appointments should be scheduled <br /> accoeding)y. <br /> 3. A filelhat Is actively being worked on by EHD staff may not be immediately available for review. A new <br /> application may be submitted when the file is available. <br /> 4. Any file not returned In the some condition as released will be reorganized by EHD staff at the expense <br /> of the applicant Future file reviews by the same applicant may require a $78..00 deposit prior to review, <br /> 5. "TENTATIVE appointment dates must be confirmed with EHD staff. <br /> S. Applications received after 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br />