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i UA7�IiEL"div eu., . <br /> SAN ,I�II�IN COUNTYPIJBLIC HEALTH S ICES <br /> �C��1�1�1DD ENVIRONMENTAL HEALTH DIVISION <br /> • r' 4�.4f <br /> 304 EAST WEBER AVENUE,THIRD FLOOR <br /> 95202 <br /> DEC <br /> I � ���Q STOClt70I+i CA <br /> (209)468-3420 <br /> pN\fIRQN�IEN-i HEALTH PE.I�L1C RECORDS <br /> RELEASE APPLICATION <br /> PER ' rla &UIHD <br /> APPLICANT uw- 94UD44nj BU5ENES5fAGENCY <br /> !! tt ] <br /> ADDRESS `7D � /�• �/�/� Q � = _ )� (� <br /> PHON2 ` (1 L! FACSIMILE b f7 f C� <br /> TENTATIVE`APPOINTMENT DATE �t r r a0 TIME <br /> (Pleats give 7 to 10 business days from data of application submi al) <br /> CHECK BOX TO EXPEDITE REQUEST•$7$•04 FEF—RE VEST PR CESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> FILE ApPUSS <br /> r r al rx# 7 �9S-3 <br /> 1 <br /> If, ELI I <br /> - s ENVIRONMENTAL HEALTH DIVISION FILES <br /> N UNDERGROUND TANK(UST)CLEANUP SITE(L,OPI 0 DOUSING ABATEMENT O SOLID WASTE VEHFACICLE <br /> F _ ❑ OTHI=R CLEANUP SITE(NOMI-LOP) ❑ FOOD FACILITY ❑ SOI.Id WASTE VEHICLE <br /> D UNDERGROUND TANK(MONITORINGIREMOVAL) 0 DoG.KENNEL ❑ DAIRY <br /> C3 IiAZARDs3US BASTE GeNERATOR. O CHICKEN RANCH C7 PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED D FACILITY C1 MOTEl1HOTEL In PUMPER TFtUCKlYARDlCHEM T09 I~TS <br /> d TATTOOIBODY PEIRCING ❑ POOLlSPA` D LAND USE APPLICATION SITES <br /> r <br /> L7 MEDICAL WASTE FACILITY O PUBLIC WATER SYSTEM M OTHER{PLEASE SPECIFY ABOVE) <br /> 1. List up to ten addresses in the space above. Selcot tyle type(s) of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(2 464-01 8 or mail to the <br />'E address neicated 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 recelpt of application. The filds <br /> will be field for a maximum of five business days for review. AppointmOnts should be scheduled <br /> 1- <br /> accordingly. <br /> 3. A file that is actively being worked on by 54D staff may not be immediately available fol review. Anew <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 rimy 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 APPQINTMENT DATE TIME <br /> ELATE CONFIRMED PHONE FAX INITIALS �r <br /> REVIEWED YES NO REVIEW DATE <br /> EM{ DG N Y]/uaioo <br />