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PUBLIC B EEA LTA SERVICES <br /> 3V]ROr MMgTAL HEALTH <br /> Pt=-IC RECORDS RELEASE APPLI&',6aON <br /> APPLICANT PHOI1B NO 0 • 0 <br /> ADDREss <br /> AGENCY N PHONE NO <br /> ADDRESS <br /> FME ADDRESS LEAD_AG CY: ATB - <br /> � r <br /> Wika <br /> S� <br /> 5 to W _ <br /> �! F <br /> s <br /> 1 <br /> THIS NOTICE IS SUSTECT TO TM REQUIREMENTS ID D IN THE C; HFAi.TIi <br /> SERvICES/ENViRONi�NTALHEALTH DMSION(EM)POLICY992-M.ORDII3AN A OF SAN <br /> JOAQUTN COUNTY, EHD FEES ANb SERVICE. CEARGE RESOLUTIONS, STATE ATR CODE, <br /> GOVERNMENT.CODE AND THE EVIDENCE CODE.. <br /> 1. A MAXIMUM OF TEN (10)PREMISE ADDRESSES PIR M,,EST: <br /> 2. PUB11C FILP-MCORDS REVIEW ARE,BY KK ONLY. Appol nNENTS ARE <br /> ARRANGED BY CALLING'(209)468.0340. OFFICE HOURS FOR INTMENI'S SCPM� <br /> MONDAY T14RU FRIDAY EXCLUDING HOLIDAYS, 8:00 A'.K TO NOON AND 1: P.X TO 4:30' <br /> P.M. ; <br /> i <br /> 3. A PUBLIC RECORDS RELEASE APPLICATION ANDA OIC-REFtINDABLFs D OS[T�OF 78.44 <br /> IS REQUIRED. DEPOSITS WILL BE RETURNED TO THE APPLICANT IF IM FILFSJ RECORDS ARE` <br /> NOT AVAILABLE WITHIN THE CUSTODY OF THF EHD. <br /> 4. THE ABOVE IDENTIFIED.DEPOSIT IS APPLIED FTOWARDS TRE TOTAL.FIL I RBVIhW ME <br /> CHARGE. THE BALANCE OF THE CHARGES ARE DUE AND PAYABLE PRIOR TO VIROING THE <br /> DOCUMENT(S). <br /> 5. PUBLIC FILESMECORDS NOT RETURNED IN THE SAME 'ONDITION AS RE WAL BE <br /> CORRBCM BY THE ERD STAFF AT THE EXPENSE;OP THE{APPLICANT. THI ADDTIIQNAL <br /> SERVICE WILL BE BILLED TO THE APPLICANT FOR PAYMENT.; <br /> 6. ORIGINAL PUBLIC FRIESWCORDS SHALT,NOT.BE REMOVED FROM THE PM&SES- <br /> SIGNATURE OF APPLICANT A., DATE ` <br /> SIGNATURE OF RM_,EASING OIC DATE <br /> IST€ 00 14 (REV 12/92) <br /> Z0'd 66029890lST 01 WMA WdiZ:I.o b66z-L0-bPJ <br />