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SAN JOAQUJN COUN'T'Y �1 <br /> a t'��o PUBLIC EM LTH SERVICES '7 Gr 1�` o)39 <br /> � <br /> XP42 <br /> ENVIRONItjF-NTAL HEALTH DIVISION J <br /> LIC RECORDS RELEASE APPLICATION <br /> r 'ti, �n v1 n P 1��-fin PITONS NO �aD9) '7 iii 7-/��i? <br /> APPLICANT `„ �,. <br /> ADDRESS <br /> AGENCY NAME 11 F �To�mlrl <br /> O <br /> ADDRESS li n) Gc�t u, 7`rac' 9sa o <br /> -41/$Tbc a�u ` BEAD AGE.INCY DATE <br /> �'IL3 ADDRESS <br /> --Z/- o <br /> -r s Tee t- - <br /> - ran* <br /> p <br /> ar k <br /> ;H]S NOTICE 1s SUBJECT TO T48 REQUIREMENTS ]DENTIFIED IN THE PUBLIC HEALTH <br /> SERvjcE5/EN%lMONbfENTAL HEALTI-I DIVISION (END) POLICY x92-007, ORDINANCE CODE OF SAN <br /> IOAQUIN COUNTY, EIAD FEES AND SER'Mr= CHARGE. RESOLUTIONS. STATE WATT>R CODE, <br /> GOVMNM=NT CODE AND THE EVIDENCE CODE <br /> 1. A MAJGDiL11.i OF TEN (10) PRE�{lSE ,kDDRE_SSES PER REQUEST- <br /> 1. <br /> PUBUC FILES/RECORDS RFVIFW ARF BY APPni]tiTA1ENT ONLY. APPOINPAENTS A.r't.- <br /> ARRANGED BY CALL-1NG (20". 8.0340. OFFICE HOURS FOR APPOINnIENTS ARE SCHEDULED <br /> NIONDAY 71-RU FRIDAY E7XCLUllINXT 14OLIDAYS, 8:00 A.M. TO 12:00 NOON AtiD 1:00 P.I.i. TO 4:30 <br /> P.14. <br /> 3. A PUBLIC RECORDS RELEASE A-PPLICATION AND A NO <br /> N.aEFU?dDABLE DEPOSIT OF 578.00 <br /> is REQUIRED. DEPOSITS AIL.L BE R=RNED TO THE .kPFLICA.NT IF THE FILE&RECORDS ARE <br /> NOT AVAILABLE WITTEIN THE CUSTODY OF THE E-ID. <br /> 4. THE ABOVE IDENTIFIED DEPOSIT IS APP1_.IF0 TOWARDS THE TOTAL FILE REVIEW FEE <br /> CHARGE. THE BALANCE OF THE CHARGF_S ARE DUE AND PAYABLE pR Q TO REVIEWING THE <br /> DOCUMENT(S). <br /> 5. PUBLIC FILFS/RECORDS NOT RETURNED IN T14E SAME CONDITION AS RECEIVED WILL BE <br /> CORp,ECTI=-D BY THE END STAFF AT INE EXPENSE OF THH APPLIC"T_ TIUS ADDITIONAL <br /> SERVICE WILT.BE BILLED TO THE APPLICANT FOR PAYM)rNT_ <br /> 6. ORIGINAL PUBLIC FIL.FSIR�CORDS SHALL NOT BE REMOVED FROM;� t <br /> THE EIiD PREMISES. <br /> ��1" DATE <br /> SIGNATURE OF APPLICAN=T— Ltijt/ <br /> SIGNATURE OF RELEASING 0 CIAL DATE <br /> Edi 00 14 (REV 12191) <br />