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i <br /> J9 til y . , • _.,i "� ;�;yii �" h'tS.i '� 11'd , t. aJ :S iV I ia"' tJ s3 L++� ( }%/-'1Llal �: �- : , :: , ... ,._ .. <br /> ENAJ)RCNMENTAL HEALTH DlW V <br /> 304 EAST WEBER AVENUE, THIRD FLC� R <br /> 570CKTON CA 95202 <br /> (209) 46$,3420 . <br /> pPul� PUPLIC RECORDS RELEASE APPLICATION <br /> APPLco.NT 11 <br /> Ck9"UtS'InLEss- �a,te—C—Y j <br /> ADDRESS <br /> PHONE FAC31MILEaW9 ' <br /> tI Tk NTAT1VE* APPOINTMENTDATE N 0 TIMENAXI <br /> Gb (Please give 7 to 16 buss days frem date of aPPII1 fion submlttaq <br /> pEl CHECK BOX YO FKPEDIT'e REQUEST00 FEE y17E"EST PROCESSED IN 3 BUSINESS PAYS <br /> SIGNATURE OF APPLICANT hl Il /I�/ °� DATE _�OZ14 01 <br /> FILE ADDRESS <br /> 3 sa.c� <br /> S 3�• a (4 ( D <br /> i <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> r ' ❑ SOLID WASTE FAGIUTY <br /> I UNDERGROUND TANK (U$7) CLEANUP SITE (I..OP) C7 }{OU'uING ABATEMENT 0 SOLID WASTE VEHICLE <br /> OTHER CLEANUP SITE (NON-LOP) ❑ FOOD FACIUTY <br /> UNDERGROUND TANK (MONITOMMUIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HA7AROOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ ' PKG THEATMENT PLANT <br /> CITIEREDPERMITTEDFACILfTY ❑ MUTFUHOTL O PUMP ERPR3YAADICHEMTOILETS <br /> ❑ 7ATT=UODY PEIRCING 1:1POOLISPA ❑ LAND USEE APPOCATIOn SITES <br /> ❑ MEDICAL WA51E FACILJTY ❑ PUBLIC WATER SYSTEM 0 OTHER (PLEASE SPECIFY ABOVE) <br /> 11 Llst up to ten addresses in the space above. Select the type(s) of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be salocted. Fax to =% 46470138 Of mail to the <br /> atij}ya' indicated above. <br /> 2. EHD will notify the applicant if any EMD tilos exist An appointment for review will he confirmed <br /> approximately five business days but no later than ten (10) days after receipt of application . The riles <br /> will be held for a maximum of five business days for review. Appointments should ho scheduled <br /> accordingly. <br /> 3. A file that is actively being worked an 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 same condition as released will be reorganized by EHD staff at the expense <br /> of the applicant. FutureIilo reviews by the Sarno applicant may require a $7a.00 deposit prior to roviaw. <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications received after 3:00 pm will be processed the next business day. <br /> L <br /> RMED APPOINTMENT DATE TIME <br /> ONFIRMED PHONE FAX INITIALS <br /> ED YES __ NO REVIEW DATE 4 <br /> M 04 14 51W40n <br />