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6AiN J" WIN COUNTYPUBLIC HEALTH : VICES ✓ <br /> log_,JVIRONMENTAL HEALTH DIVISIC, <br /> 304 EAST WEBER AVENUE, THIRD FLOOR I <br /> STOCKfON CA 95202 <br /> (209) 468-3420 <br /> PUBLIC RECORDS RELEASE APPLICATIO ` <br /> APPLICANT n ill S ES51AGENCY Q(1(IC1'I UC.✓ tjl.,-D ' Q �y7rt� <br /> ADDRESS LI D J- G{Jl l SD C Q C '7 �/7 �j _Iq�/?Ac;,r,. T rf S <br /> PHONE �D -IQ FACSIMILE <br /> TENTATIVE"APPOINTMENT DATE TIME <br /> (Please give 7 to 10 tausini:ss days from date of application submIMI) <br /> *CHECK BOX TO EXPEDITE REQU T-S78.00 FEE—REQU S PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPL(CAN DATE <br /> FILE ADDRESS <br /> LOW INIA <br /> � r <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT O SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON•LOP) ❑ FOOD FACII.JTY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGtREMOVAL) C1 DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR D CHICKEN RANCH CJ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTrFUHOTI I, O PUMPER TRUCKIYARD/CHEM TOILETS <br /> ❑ TATTC�OfQOVY PEIRCING D POOUSPA ❑ LAND USE APPLICATION 5ITE5 <br /> n MEDICAL WASTE FACILITY ❑ PUBLJC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1_ List up to ten addresses In the space above. Select the type(s) of files from tale list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to (209)_464-0138 or mail to the <br /> address indlcatod above. <br /> 2 EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> approximately five business days but no later than ten (10) days 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 /> 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. Future file reviews by the same applicant may require a $78.00 deposit prior to review. <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 /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EH 00 14 OUGNOU <br /> q , OCA c�_M <br />