Laserfiche WebLink
r <br /> SAN JOAQU V COUNTY <br /> PUBLIC nEALT H SERVICES <br /> I�-VIItONA'I�mrAL HEALTH DIVISISN <br /> CLIC RECORDS RELEASE APPLICATION <br /> APPLICANT Ame so" PHONE NO <br /> ADDRESS <br /> AGF24CY NAME1dvamc �j�o ��i✓iyoYl�'�•c1 a PHONE NO q. �'O•�6 <br /> ADDRESS 1$O W flat-c Ln.• f�� 5 ec }a "' <br /> FTL$ ADDRESS LEAD AGENCY DATE <br /> YZZ C/•err PA;-e kyl, <br /> 41024 ty) 1414 <br /> TI-US NOTICE ISS SUBJECT TO THE RFQL'IRE-NSE-NTS IDENTIFIED IN 131E PUBLIC HEALTH <br /> SERVICESIENVIRON.MF.\'TAL: F-.k .T14DIVISION(FHD)POLICY x'42-007,ORDI:�ANaCE CODE OF S.A- <br /> JOAQUIN COUNTY, F-14D FRES AND SERVICE CHARGE RESQLUTIOKS, STATE NATER CODE, <br /> GOVERNS(E,NT CODE AND Tri EVIDENCE CDDI<. <br /> 1. A t�iA U' IUAi Or- TEN, (10)PREAiISE ADDRESSES PER REQU]✓Sl'. <br /> 1. PUBLIC 17LESlRLCO cDS REVIL-1V ARE-BY APPOINT? lqT O:4'LY. APPOIN117MENTS ARE <br /> ARRANGED BY CALLING ('.x9)453-03:.0. . OFFICE HOURS FOR APPOI�NTIAiI,NTS ARE SC1413 ULE <br /> MONDAY THRU FRIDAY EXCLUDING HOLIDAYS, 8:170 A-M-TO 13:00,'NOON AND 1;00 P.M. TO 4:30 <br /> P.M. <br /> J. A PUBLIC RECORDS RELEASE APPLICATION AILD A NnN-REFUNDABLE DEPOSIT OF S78.00 <br /> IS REQUIRED. DEPOSITS W1i r BE Rr-MFUN D TO THE.�ll'PLICANT IF THE FILI~S/RECORDS ARE <br /> NOT AVAILABLE W171UN THE CUSTODY aF THE EHD. <br /> d. THE ABOVE IDENTIFIED DEPOSIT IS APP11ED TOWARDS 714E TOTAL FILE REVIEW FEE <br /> CII.4.1tGE. TBE$ALANdCE OF THE CHARGES ARE DUE AND PAYABLE 'R10R TO RF_V]E�V1NG ?NE <br /> DOCUMENT(S). <br /> 5. PUBLIC E"ILES/RECORDS NOT RETU1 WTI)IN THE SAME CONDITION AS RECEIVED WILL BE <br /> CORRECTED BY THE EHD STAFF AT THE .EXPENSE OF THE APPLICANT. '1141S AADITIONAI- <br /> SERVICL- WILL BE BILLED TO THE APT <br /> PLICANI:OR PAYI+lENT. <br /> 6. ORIGINAL PUBLIC FILFS/RFCOIMS SHALL NOT BE REMOVED FROM THE F-HD PREMISES- <br /> SIGNATUROP APPLICANT "p DATE !7'St r`f99 <br /> E <br /> SIGNATURE OF RELEASING OFFICIAL DATE <br /> 1;H 00 I d (REV 17192) <br />