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SA -N JOAQUIN COUNTY <br />M13LIC HEALTH SERVICES <br />ENvJJk0N1MEIENTAL HEALTH DIWSION <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT KQ, t l PHONE No�ao <br />ADDRESS _- -( c k • , O/ r < as <br />AGENCY NAME ; - .t <. PHONB NO ,_�1 _e <br />ADDRESS 01 -IL- <br />1— <br />')'>_— <br />1- 4 f E/ l C� (Y �,, I m a vi Vi e, v J. <br />ELLE ADDRESS LEAD AGENCY DAT73 <br />T?IIS NOTICE IS SUBJECT TO THE REQUIREMENTS IDENT=D IN THE PUBLIC HEALTH <br />SERVICES/ENVIRONMENTAL REA LTH DIVISION (EHD) POIICY #92-007, ORDINANCE CODE OF SAN <br />JOAQUIN COUNTY, EHD FEES AND SERVICE CHARGE RESOLUTIONS, STATE WATER CODE., <br />GOVERNMENT CODE AND THE EVIDENCE CODE. <br />1. A MAXIMTJM OF TEN (10) PRENUSE ADDRESSES PER REQUEST. <br />2. PUBLIC FILESIRECORDS REVIEW ARE BY APPOINTMENT ONLY. APPOINTMENTS ARE <br />ARRANGED 13Y CALLING (209)468-0340. OFFICE HOURS FOR APPOINTMENTS ARE SCHEDULED <br />MONDAY THRU FRIDAY EXCLUDING HOLIDAYS, 8:00 A.M. TO 12:00 NOON AND 1:00 P.M. TO 41.30 <br />P.M. <br />3. A PUBLIC RECORDS RELEASE APPLICATION AND A NON- FUNDARLBDEPOSITOP $78.00,�>:` ...: <br />IS REQUIRED. DEPOSITS WILL BE REnJRNED TO THE APPLICANT IF THE FILMS/RECORDS ARE <br />NOT AVAILABLE WITHIN TI-II3 CUSTODY OF THE EHD. <br />4. THE A13OVE IDENTIFIED DEPOSIT IS APPLIED TOWARDS THE TOTAL FILE REVIEW FEE <br />CHARGE. THE BALANCE OF THE CHARGES ARE DUE AND PAYABLE F TO REVIEWING 11M ' <br />DOCUM N T(S). <br />S. PUBLIC FILES/RPCORDS NOT RETURNED IN THE SAME CONDITION AS RECEIVED WILL 13E <br />` CORRECTED BY THE EHD STAFF AT THE EXPENSE OF THE APPLICANT. THIS ADDITIONAL <br />SERVICE WII-L Bfi BILLED TO THE APPLICANT FOR PAYMENT. <br />6. ORIGINAL PUBLIC FILES/RECORDS SHALL NOT BE REMOVED FROM THE ERD PREMISES. <br />SIGNATURE OF APPLICANT <br />SIGNATURE OF RELEASING OFF10AL <br />EH 00 14 (REV 12/92) <br />DATE 1// -2 <br />1pt :l <br />�7'� �6SLTSS r1 WONT WUSZ:TT 266T -9Z-80 <br />OL �. <br />c �. � U�Cl � lei /1�5 <br />y <br />`,1'� l�, <br />I11iIr/1 <br />�- <br />E�l -�;� ��' �-� ,t��a�i✓tc-"; %Py��� <br />r i <br />rl <br />.S� _ <br />i l n,�ti,�,�ri I_t.i.mho f- <br />T?IIS NOTICE IS SUBJECT TO THE REQUIREMENTS IDENT=D IN THE PUBLIC HEALTH <br />SERVICES/ENVIRONMENTAL REA LTH DIVISION (EHD) POIICY #92-007, ORDINANCE CODE OF SAN <br />JOAQUIN COUNTY, EHD FEES AND SERVICE CHARGE RESOLUTIONS, STATE WATER CODE., <br />GOVERNMENT CODE AND THE EVIDENCE CODE. <br />1. A MAXIMTJM OF TEN (10) PRENUSE ADDRESSES PER REQUEST. <br />2. PUBLIC FILESIRECORDS REVIEW ARE BY APPOINTMENT ONLY. APPOINTMENTS ARE <br />ARRANGED 13Y CALLING (209)468-0340. OFFICE HOURS FOR APPOINTMENTS ARE SCHEDULED <br />MONDAY THRU FRIDAY EXCLUDING HOLIDAYS, 8:00 A.M. TO 12:00 NOON AND 1:00 P.M. TO 41.30 <br />P.M. <br />3. A PUBLIC RECORDS RELEASE APPLICATION AND A NON- FUNDARLBDEPOSITOP $78.00,�>:` ...: <br />IS REQUIRED. DEPOSITS WILL BE REnJRNED TO THE APPLICANT IF THE FILMS/RECORDS ARE <br />NOT AVAILABLE WITHIN TI-II3 CUSTODY OF THE EHD. <br />4. THE A13OVE IDENTIFIED DEPOSIT IS APPLIED TOWARDS THE TOTAL FILE REVIEW FEE <br />CHARGE. THE BALANCE OF THE CHARGES ARE DUE AND PAYABLE F TO REVIEWING 11M ' <br />DOCUM N T(S). <br />S. PUBLIC FILES/RPCORDS NOT RETURNED IN THE SAME CONDITION AS RECEIVED WILL 13E <br />` CORRECTED BY THE EHD STAFF AT THE EXPENSE OF THE APPLICANT. THIS ADDITIONAL <br />SERVICE WII-L Bfi BILLED TO THE APPLICANT FOR PAYMENT. <br />6. ORIGINAL PUBLIC FILES/RECORDS SHALL NOT BE REMOVED FROM THE ERD PREMISES. <br />SIGNATURE OF APPLICANT <br />SIGNATURE OF RELEASING OFF10AL <br />EH 00 14 (REV 12/92) <br />DATE 1// -2 <br />1pt :l <br />�7'� �6SLTSS r1 WONT WUSZ:TT 266T -9Z-80 <br />