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1 SAN JOA.,-jIN COUNTYPUBLIC HEALTH SE. _, ICES <br /> ENVIRONMENTAL HEALTH DIVISION _ <br /> \\ 304 EAST WEBER AVENUE,THIRD FLOOR <br /> ')f � CI�TON CA 95202 <br /> (209) 468-3420 . <br /> PUBLIC RECORDS RELEASE APPLICATION_ <br /> APPLICANT re Q �`"�� BUSINESS/AGENCY � <br /> ADDRESS oLS�S� I <br /> PHONE \ \ "( FACSIMILE <br /> TENTATIVE"APPOINTMENT DATE TIME <br /> (Please rui c 7 t0 10 busincss days from date of application:�ubmitWt) <br /> QTS 3, �/- <br /> HECK 13OX TO,EXPEDITE REQUEST-$07.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF 4PPLICANT <br /> DATE <br /> FILL"ADDRESS THIS SIDE EHD STAFF USE ONLY <br /> PROGRAM ELEMENTS SEARCH <br /> d"V-L S 1� <br /> Av-, <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> ZDERGROUND TANK(UST) CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE"GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ PAOTEL/HOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> O TATTOOIBODY P41RCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WAsTI1 FACILITY ❑ PUBLIC WATE=R SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1. List up to ten addresses in the space above. Select the types) of files from the 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 indicated 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 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 condition as released will be reorganized by EHD staff at the expense <br /> of the app,licant. Future file reviews by the same applicant may require a $87.00 deposit prior to review. <br /> 5. "TENTAT.tVE 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 /> LH 00 14 00/07100 <br />