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F' SAN ,�_03-1�2FJ(30 09=1M FROM ")G Xt'hA4-R <br /> ':"ZUIM COUNTYPUBLIC HF-PLTiq <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 FAST WEUR AVENUE,TMRD FLOOR tlX <br /> STOCKrON CA 95202 <br /> 001 (209)468-3420 <br /> iI- RMORDS RELEASF APPLICATION <br /> H-AU H pUBLIG-li <br /> YS-CL-;—'o-n <br /> 'APPL•ICAN <br /> ADDRESS _72- <br /> to L4- 22-PO FACSIMILE <br /> '11ME <br /> TENTATIVE'APPOINTMENTDA-Mappilptian submi <br /> ME-RaCt/ySEP IN 3 BUSIIIrISS DAYS <br /> EVPROCF- <br /> OATE <br /> SIGNA-r RE OF APPLICANT <br /> SE ariLy <br /> ..................I.......................... <br /> rjLF_A00RIESS pRoGnAM ELEMENTS SEARCH <br /> o <br /> o <br /> EinVIRONMEtITAL HEALTH 13nnsioN FILES <br /> ANUpSITg( TE FACILRY <br /> CLrLop) C1 lJoUSING ABATPMENT <br /> )3(UNDF- ftOUND TAKK(UST) _ D FOOD FACILITY CO3 $0 PWASTIMHICI-15 <br /> -r <br /> --kig g CLEAKup S11-9(NON-LOP) 0 DOG KrENNEIL 0 DAIRY <br /> LIND GWuND'rANK(M0NtT0RI?4=5h10VALI c3 cHicW9W RANCH rn PKQ TREATMANT PLAM <br /> 0 PUMPER TRUCMARwuHF-M TOILM <br /> HAZ us wA4*M GENOZATOR 13 MOMMOTEL M SIM <br /> PERMITTED FACILITY APPLICALTIO <br /> Cj TJAKE 0 POOLAPA 0 LAND USE <br /> ❑ TATTOBODY PEIRCING M PUBLICWATER$YSTV;M 0 OTHER(pLLASE SPECIFY ABOYM <br /> cl MpolM WASTE FACILM e. Select the"(5)of fil"'Mm tho list above by 0heOldrig <br /> 1. List up to ton addresses in thC%PaC0 ab*v a MU$-r be selected. FAX 209 13 r mal le <br /> the appropriate box(es). At least one file type estdr5155 <br /> confirmed <br /> 2. EH will n otify <br /> in AL04 0-ov 0- ointatent far feVleW Will be <br /> the applicant If Any EHO files exist An AP <br /> p <br /> approximately I'me bUlln2ss days but no later than ten(10)dayr,after recal pt 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 aotively b.eing worked or'by EHD qj2fr may not be immediately availablo for review. Anew <br /> applicatiO41 may be submitted when the file Is avaitAble. <br /> 4. Any the not returned in the Came condition as released will be rawganized by 9HD staff at thD eXPOnse <br /> . <br /> of the3ppliCarit. future file reviews by the SaMe applicant may require a$78.00 deposit prior tu review <br /> 6. *TENTATIVE appointment dates must be confirmed with EHD etaff. <br /> 6. Applications received after 3:00 pM Will he prautrMed tho next bVelness day. <br /> CONN MED APPOINTMENT DATE TIME <br /> DAT <br /> TE C NFRM1pED PHONE FAX INITIALS <br /> _�Jj <br /> YES NO REVIEW DATE <br /> 00 54 VE00 <br /> TOTPL P-02 <br />