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v-vLa:r 'r -vas:. ;'I w,i'GCJ �i( tie: f• ora <br />SAN JC 1UIN COUNTYPUBLIC HEA1-TH S VICES <br />Q�] NVIRONMENTAL HEALTH DIVI510D1 <br />r[jV �� 304 FAST WE6Eli AVENUE, THIRD FLOOR <br />STOCKTON CA 55202 <br />�0 C T 16 2000 (202) 468.3420 <br />PUI31-IC RECORDS RELEASE APPLICATION <br />Ad`%Ahn?f"coI,7LdID�1ZJc�J�J 6USINESSIAGENCY (/S G'Q2F -- <br />PHONEFACSIMILE %l Y�ry <br />TLNTATIvE' APPAN49 d /.'00 <br />1M <br />tI {Please qae Y . 7o Du w.a p from aate of app4"VDn subminall <br />+-� CH:cK BOX TO EXPEDITE 9E4UE5W-0 FEE- R oL BT RROCES3£A +» 7 &USfNE=rs DAYS <br />SIGNATURE OF APPLICANT J�"r PATE <br />i <br />ENVIRONMENTAL. HEALTH DIVISION FILES <br />l uNDEKGROUND TANK (u5T) CLEANUP S4TF 1WI41 Q HOUSING ABATEMENT O SRLIP WASTE FAM" <br />f OTtir;g CLEANUP 5n•C (NOni-RPI R FOOD FAc wTY M SOUP WASTE VEHICLE <br />�F UNPGFTGRAUNA TANK [Id ONITRF:INGlREMOVALI ❑ DOG KENN" O DAIRY <br />M hA7gRPOU5 WASTE GENERATRR ❑ CHICKEN RANcl1 CI PKG TREATMFNT PLANT <br />17 TIERERPER'MITTIEDFAC+LRI' M LtRTF.Lrf=L O PUMPER TRU,gKrVARWCREM TQ" -M <br />G TATTOUNUPY Pf1RGING Q POOttSPA . - ❑ LAND USE APPLICATION SITE5 <br />M MEAICAi-wA5TE FACILITY C1 PUBLIC WATER SYSTEM C OTHER (PLEASE 5P6GIFY ABOVE) <br />9. list up to ten addresses In the space above. Select the type(5) of files from the list above by chaclanq <br />the appropriate box(esJ. At least one file type MUST be selected. Fax to (2(191!154-0138 a[mall t the <br />address indicated abam <br />pHla will notify the applicant it any EHA files exist An appointment for review will ha confirmed <br />approximately five business days but no later than ten (10I days atter ret:aipt of application. The files <br />will be held for a maximum of five business days for review. Appointments should be scheduled <br />aGaard)nyly. <br />�. A file that is actively being worked on by EHP sraff may not be immediately available for review. A riew <br />application may de suAmiiteq when the file is available. <br />�. Any file riot retumed in the lama condition as relcasad will be mweanized by ENA staff at the expense <br />of the applicant Futura file reviews by the same applicant may require a $87.00 deposit prior to review- <br />-TENTATIVE <br />eview_- TENTATIVE appointment datcs must be confirmed with EHP staff. <br />Applications received after Z.00 pm will be processed the next business day. <br />6ONFIRMED APPOINTMENT DATE TIME <br />PATE CONFIRMED PHONE IFAX INITIALS <br />I <br />}REVIEWED YES NO - aFvlFw npYF <br />'GJYI'�•'Glji�7i <br />i � ., .- , . <br />iil�'i'��/�I/I�LIC�'7 <br />ENVIRONMENTAL. HEALTH DIVISION FILES <br />l uNDEKGROUND TANK (u5T) CLEANUP S4TF 1WI41 Q HOUSING ABATEMENT O SRLIP WASTE FAM" <br />f OTtir;g CLEANUP 5n•C (NOni-RPI R FOOD FAc wTY M SOUP WASTE VEHICLE <br />�F UNPGFTGRAUNA TANK [Id ONITRF:INGlREMOVALI ❑ DOG KENN" O DAIRY <br />M hA7gRPOU5 WASTE GENERATRR ❑ CHICKEN RANcl1 CI PKG TREATMFNT PLANT <br />17 TIERERPER'MITTIEDFAC+LRI' M LtRTF.Lrf=L O PUMPER TRU,gKrVARWCREM TQ" -M <br />G TATTOUNUPY Pf1RGING Q POOttSPA . - ❑ LAND USE APPLICATION SITE5 <br />M MEAICAi-wA5TE FACILITY C1 PUBLIC WATER SYSTEM C OTHER (PLEASE 5P6GIFY ABOVE) <br />9. list up to ten addresses In the space above. Select the type(5) of files from the list above by chaclanq <br />the appropriate box(esJ. At least one file type MUST be selected. Fax to (2(191!154-0138 a[mall t the <br />address indicated abam <br />pHla will notify the applicant it any EHA files exist An appointment for review will ha confirmed <br />approximately five business days but no later than ten (10I days atter ret:aipt of application. The files <br />will be held for a maximum of five business days for review. Appointments should be scheduled <br />aGaard)nyly. <br />�. A file that is actively being worked on by EHP sraff may not be immediately available for review. A riew <br />application may de suAmiiteq when the file is available. <br />�. Any file riot retumed in the lama condition as relcasad will be mweanized by ENA staff at the expense <br />of the applicant Futura file reviews by the same applicant may require a $87.00 deposit prior to review- <br />-TENTATIVE <br />eview_- TENTATIVE appointment datcs must be confirmed with EHP staff. <br />Applications received after Z.00 pm will be processed the next business day. <br />6ONFIRMED APPOINTMENT DATE TIME <br />PATE CONFIRMED PHONE IFAX INITIALS <br />I <br />}REVIEWED YES NO - aFvlFw npYF <br />