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flij S,��N J UIN.COUNTYPUBLIC HEALTH S ICES VIRONMENTAL HEALTH DiVISIOMW 304 EAST WEBER AVENUE, THIRD FLOOR MAR 1-4 2061 sTOcxTOrl CA 95202 �- (209) 4683420 ENVI ;UN!M4_71"a; L!EALTH P i�iLIC RECORDS RELEASE APPLICATION nr.� • , ,. _..I1 iii .f _ ♦ n _ • ! _. - .. .. • ' ^ :✓l " .'' ' il%lf/R;r iia r /,��L// Jif�:,r� NTATIVE" APPOINTMENT DATE Z (Please give T to tQ be CHECK BOX TO EXPeo1TE REQU ?T1400 FEE SIGNATURE - SIGNATURE OF APPLICANT 2 Q 111 _ TIME rA/ days from date of applicatlan submittal) TPROCFSSED IN 3 BUSINESS DAYS � DATE I s a+n o1��5t s? ENVIRONMENTAL /A S . 8jAll /,�. m -1 ❑ HOUSING ABATVAENT 0 SOLID WA$T�P UT -Y OTHeR, CLEANUP SITE (NON -LOP) OUNW1: • Ami- r r,,�Tf liia1.: 1M.11�Il1'IIIN�I�f t 1! IID ATE VEHICLE ,X-UNUERGROUND TANK (MONITORINGIREMOVAL) I 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or maid to the address' indicated above. 2. EHD will notify the applicant if any EHO files exist. An appointment for review will be confirmed approximately five business days but no later than ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by EHO staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned In the saltie condition as released will be reorganized by EHO staff at the expense of the applicant. Future -file reviews by the same applicant may require a $78.00 deposit prior to review. 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. 6. Applications received after 3:00 pm will be processed the next business day. CONFIRMED APPOINTMENT DATE TIME DATE CONFIRMED PHONE' FAX INITIALS REVIEWED. YES NO REVIEW DATE EH 130 .a 01MM s a+n o1��5t s? ENVIRONMENTAL HEALTH DIVISION FILES MWiE 1 UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATVAENT 0 SOLID WA$T�P UT -Y OTHeR, CLEANUP SITE (NON -LOP) 13 FOOD FACILITY 1! IID ATE VEHICLE ,X-UNUERGROUND TANK (MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY >C-ARQDUS WASTE GENERATOR ❑ CHICKEN RANCH 17 PKG TREATMENT PLANT E3 TIERED PERMITTED FACILITY ❑ MOTE -1-1 1014L E3 PUMPER TRUCKIYARIXCHEM TOILETS ❑ TATrOD/DORY PORCING ❑ POpuSPA Q, LAND USE APPLICATION SMS 13 MEDICAL WASTE FACILITY ❑ PU$ttG WATER SYSTJ i_M `!L�` OTHER (PLEASE SPIECIFY ABOVE) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or maid to the address' indicated above. 2. EHD will notify the applicant if any EHO files exist. An appointment for review will be confirmed approximately five business days but no later than ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by EHO staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned In the saltie condition as released will be reorganized by EHO staff at the expense of the applicant. Future -file reviews by the same applicant may require a $78.00 deposit prior to review. 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. 6. Applications received after 3:00 pm will be processed the next business day. CONFIRMED APPOINTMENT DATE TIME DATE CONFIRMED PHONE' FAX INITIALS REVIEWED. YES NO REVIEW DATE EH 130 .a 01MM