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-KU LUU NUMLWIC <br /> SAM- AQUIN COUNTYPUBL C HEALTH�RVICES <br /> 006ST <br /> ONMEI1tTAL HEALTH DIVISION �j- 05IV 1 <br /> WEBER AVENUE.THIRD FLOOR <br /> STOCKTON CA 95202 <br /> (209)468-U20 <br /> FEB 20UMI+C RECORDS RELEASE APPLICATION <br /> T <br /> L <br /> y�'1��1 1� LT BUSINESSAGEN <br /> APPLICAN <br /> _�� i <br /> ADDRESS ti I <br /> PHONE jjj. - FACSIMILE <br /> TENTATIVE*APPOINTMENT DATE j TIME — f — — <br /> (Please give 7 to 10 business days from data of application submittal] <br /> HECK BOX To F-XPE131TE REQUEST-$78.40 FEE--REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> DATE , �• <br /> SIGNATURE OF APPLICANT <br /> �`,yb Filt:aaglxes i <br /> I <br /> E I <br /> D� 1 <br /> ENVIRONMENTAL HEA TH DIVISION FILES <br /> /� ❑ HOUSING A TEMENT 0 5OUD WASTE FACILITY <br /> W ll' NDERGf20UNaTAN1S(UST)CLEANUP 51rE(LOP) ❑ FOOD FACIL TY 0 SOLID WASTE VEHICLE <br /> ❑ pT HER CLEANUP SITE(NON-LOP) ❑ DOG KEN HE 11 DAIRY <br /> W UNDERGROUND TANK(MOFIITORINGIR£MOVAL) ❑ CHICKEN W NCII ❑ PKG TREATMENT PLAKY <br /> ❑ HAZARDOUS yyAsirE GENERATOR © MOTEiJHfl KI <br /> L ❑ PUMPER TRUCYARDICHEIII TOILETS <br /> R TIERED PERMITTED FACILITY 0 POO❑SPA ❑ LAND USE APPUC;ATION SITES <br /> 0 TATTOO)BODY PEIRCING ❑ PUBLIC VWAIJER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE} <br /> 0 M€DIGAL WASTE FACILITY <br /> 1, List up to ten addresses in the space above. Sel ct the type(6)of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. F 2019 464-01R or - 'I to 1h <br /> address indicat above <br /> 2, EHD will notify the applicant it any EHD files exk t An appointment for review will be confirmed <br /> approximately five business days but no later th n ten(10) bays after receipt of application. The files <br /> will be held for a maximum of five business days for review. Appointments should be scheduled <br /> accordingly. <br /> g. A file that is actively being worked an by El-ID s ff may not be immediately available for review. Anew <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. Future file reviews by the Same applicant may require a$713.00 deposit prior to review. <br /> g- *TENTATIVE appointment dates must be cont' ed with EHD staff. <br /> g. Applications received after 3:00 pm will be pros ssed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> PH NE FAX INITIALS <br /> DATE CONFIRMED <br /> IREVI=WED YES NO REVIEW DATE <br /> &4 00 14 011Q7A0 <br />