Laserfiche WebLink
i <br /> SERVICE REQUEST - (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # F <br /> INVOICE # <br /> F L <br /> FACILITY NAME 1'4�14=4 <br /> SITE ADDRESS �O�J � S <br /> CITY �1 dG/C"�D7'l CA zip 1 S/ZU5 1995 <br /> OWNER <br /> YJU�/,! y /L/!C/V �d 81L N��Tcry tri / N <br /> DBA l�WG T C / �' '`� PHONE #1�c•?_�) �9 SS <br /> JV ADDRESS 31,:?`-1-f7 DN HiQ PHONE #2 ( ) <br /> CITY �1 ��/ STATE zip <br /> �=apN # F=Land Use Application # <br /> BOS Dist i ( Location Code <br /> L <br /> -ONTRACTOR and/ <br /> 11—XX1210 'I <br /> SERVICE REQUEST( LONE TREE RANCH 172 <br /> / N <br /> ROBERT KOLBO <br /> DBA SUELLEN KOLBO <br /> 10478 RODDEN RD (209) 847-9455 �T <br /> OAKDALE, CA 95361 <br /> MAILING ADDRESS '1 <br /> rnr TO THE N\v 'yo <br /> ORDER OF <br /> CITY: 'o I� DOLLARS <br /> BILLING ACKNOUI [ Bank of America ect specific <br /> Oakdale stanch 0404 A?,�J g, T <br /> PNS/EHD hourly 305 East FStreet AYM NaPARTY on <br /> Oakdare.CA95361 (209) 549-8280 ����� ED <br /> Page 1 of this ---- <br /> MEMO -- a�'n <br /> 1 also certify 1: 1 2 1000 3 581:0 17 2��10404 S"'0 3 54 111' ,�11N i n�ll SAN <br /> JOAQUIN COUNTY ` <br /> PUB!IC HEALFH SE?VICES <br /> StVC FNTALHEAL; DIVISIQN <br /> APPLICANT'S SIGNATURE <br /> Date' 1, �7•7S <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirormentaL/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> 7M <br /> �) �T <br /> Nature of Service Request: Servic�eC ode <br /> Assigned to Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount FAmount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS / / SUPV _/ / TACCT _/ / UNIT CLK _/ / <br />