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6Ai4 ji .IiN CUUNTYPUSUC HEALYH SIk ICES <br /> - VVIRONMENTAL HEALTH DIVISIS0 <br /> 304 EAST WESER AVENUE,THIRD FLOOR <br /> STOCKfON CA 95202 q <br /> (209)468-3420 <br /> ' I P1 BLIC RECORDS RELEASE APPLICATION _ <br /> RPPUCAtcT �� (7,� eu�u��ssrac[ucY SSD�nP .�i'}�?11��I7rt-� �� • <br /> AMPESS,)00o <br /> PHONE Rt�` 961— FACS INLE `/�& <br /> ,o Il:3o A m <br /> TENTATTVE`APPOINTMENT PATE-Q,1Q;fiVG Gi/o1L0I —77I ,4tQ�G (D dlC� YTir1q�IZ� a oQtrt7*wlf <br /> (Please give 7 CQ 90 business stays Crum II of appiiaaSan submittal) �•f . <br /> Grp Dui ,tx.��f <br /> CHECK BOX TO EXPEDITE REOUSST-SB7.00 FEL—REQUEST PROCE$SEU IM 3 BUSINESS DAYS <br /> SIGNATURE OF ALPPUCANq rJ,r DATE <br /> FILE ADDRESSO <br /> THIS SIDE END STAFF USE ONLY. <br /> PROGRAIA ELESICNTS SEARCH ' <br /> NFF S o S/ of c lodr <br /> D w <br /> � <br /> a 66,20 41�- ! I re <br /> Ak <br /> dFFAfa S4tim 0,5 4J &toa <br /> ENVIRONMENTAL HEALTH DIVISIO FILES F ,qZ <br /> U D <br /> i � <br /> i✓OTHER CLEANUP SITE <br /> (UST)CLEANUP$CIE(LOP) U HOUSING Al9ATEMENT ❑ SOLID WASTE FAC1LfTY 2 7 <br /> d OTHER CLEANUP STrE(NON-LOP) O FOOD FACILITY ❑ SOLID WASTE VEHICLS- <br /> l�Ut10ERGIZOUIrn TANK(tIONITCI N&REMOVAt~) ❑ DOC{KENNEL ❑ DAIRY <br /> Q FIVAR00US WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITrEO FACIU-yY 0 140TELtHOTEL Q PUMPER TRUCKIYAR=HEM TOILETS <br /> 0 TATTOOJBODY PEIRGING O POOL!$PA - 4 LAND U$EAPPWIZATION SITES <br /> 0 IJEDICAL WASTE FAClLI Y 73 PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFYA80VE) <br /> 1. List up to ten addresses in the spaca above. Select the tyAe(s) Of files from the list above by checking <br /> the appropriate box(es). At[east one file type MUST be selected_ Fax to (209) 4640139 or mall to the <br /> a0dress Indicated above. `- <br /> 2. EHD will notify the applicant it 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 /> vsrilf be hold for a maximum of five business days for review. Appointments should be scheduled <br /> accordingly, <br /> 3. A fife that is actively being worked on 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 condtion as released will be reorganized by EHD staff alt the expense <br /> of the appl[cant. Future file reviews by the same applicant may require a $87.00 deposit prior to review. <br /> 'Tt=IhfTATIVE appointment date*mast be confirmed with EHD Sniff, <br /> G• Applications reGCived after 3;00 pm wilt be processed the next business day. <br /> CONFIRMED APPOINTNlIENT DATE Tl1iRE <br /> DATE UONFIRMEo PHONE FAX iNITtALS <br /> VM,rIPWC!n YCC kin oC1/IC1wi r1AYc <br />