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--.. ... _•ti....SAN <br /> .T.r-1-,.{.--(-,---_(''(.'.,.Y-{.�7+7�Yj-— -—_ {.� f-N y - ,( <br /> / 0 S�'�l, JuF'►Q xN COVA's ' .l � I � � \.� ��+++1Jl I (, l {.' <br /> FTTRL.It" HEALTH S�VICX-S lti <br /> �. FNL V-fRo N31+IFN'I'jjL REALTH DIVISI+E]I`(. <br /> PUBLIC RECORDS RELEASE+ APPLICATION <br /> APP11CAN-1- cz ru�-d PHONE No �9� � n -� � <br /> ADDRESS <br /> AGENCY NAME PHONE gra <br /> DATE <br /> SJSA2. �l.J.R.cr__y7.Y <br /> r�x.41 �I1E.l. <br /> TM5 IS 171TH FC-7V TO THE REQUIIiI 4M4—I'S IDEN W TI-1E PUBLIC HFAf"M <br /> SF=.RVTCF,3mNVTRC3[ M�T,",LHEIALTH DIVISION (EHD)POLICY#92-MI,0RDINA.iqCFf CODE OF SAN <br /> ]L)AQUIN COUNTY, EHID FEES AND SERvEt7F cg,�RGE RFSOLUL'ONS, STATE WATTR CODE, <br /> GOVERNMENT CODE AND THE EVIDENCE CODE. <br /> 1_ A MAMMUM OF TEN (I(3) PFF_t►riTSF, ADDRFMES PER REQUEST. <br /> Z yUBLIC FiLESJREC(DRj)S .REVIEW ART: BY : F 1 O A�'OL3�iTI4f�I^7'r5 ARE <br /> A RANGM 13Y CAIJING (209)4()8--034()- i]MCE ITC)URS I'OR AFPODMAENTS ARE SCiTII�[�`LEO <br /> MONDAY THRU FRIDAY ECCI.UDII`1G HOLIDAYS, 8:00 A.M. TO I2:W N0014 AND I.40 P_M. TO 4:313 <br /> Y.ivl_ <br /> 3. A n'I Ruc eE[.:UI1 s RELRASE APPLICATION AND A No-t+I-RUUNDARLE DEPO=OF$73.00 <br /> iS REQUIRED. DEPOSTT3 wTLL BE RMIMNED TO THE APPLICANT W THE FTIEST-EC©R.DS ARE <br /> NOT AVAIL J9LC MTM TTIE' CUS'T'ODY OF THE ERD' <br /> 4. TIMI~ ABOVE TT)ENTJFTSD DEPOSIT IS APPL-MD 'T'O'WARDS THE TOTAL, FILE REVIEW FEE <br /> CH,\RGE. THE BAL.'S WCL3 OF IRE CFf.4RGES AitE`s DUE AND FAYABLE PRIOR TD REN'IEWIN() THE <br /> DOCUMENT(S). <br /> 3. PUBLIC Ffi.ESlI, cORK)s NOT RETURNED LN THE SAME CONDIT TON AS RFM— VET)WILL BE <br /> C,()RIZBCT"F D BY THE EIM STAI'T' AT 'THE E FNSE OF TRE A£'FIIC YT_ TENS ADI?I OI`#AL <br /> SERVICE WiL.L sE's mLLED TO Tur. AR`TL.ICAN`I'FOR f AYMII`1T. <br /> 6. ORIGINAL PUIILIC FILES/RECORDS SHALL NOT BE REMOVED FROM THE FHD I?LtF–NiISES_ <br /> SIGNATURE OF APP]UCANT DATE <br /> SIGN ATURE OF R ELEASING OFVICIAL DATE <br /> 1 <br /> Fff OQ I4 (REV (2/92) <br /> TfIT01 F.LI- <br />