COMPLIANCE INFO_1995-2011 - Laserfiche WebLink

Home Browse Search

SERVICE REQUEST CEH 00 61) Revised 8/23/93 F�CILITY ID # RECORD ID # ! VOICE # I FACILITY NAME RMC Lonestar, Inc. BILLING PARTY Y / N SITE ADDRESS 30350 South Tracy Blvd. , CITY Tracy CA ZIP 95376 OWNER/OPERATOR BMC Lonestar, INC. BILLING PARTY al N DBA game PHONE #1 ( 510 > 426 -2279 ADDRESS P.O. BOX 5252 PHONE 42 ( ) CITY Pleasanton STATE CA ZIP 945616 APN # IF and Use Application # BOS Dist Location Code 7-1 CONTRACTOR and/or Pacific Excavators SERVICE REQUESTOR BILLING PARTY Y / N DBA same PHONE 41 ( 510 ) 370 -8783 MAILING ADDRESS P.O. BOX 968 FAX # ( 510 ) 939 - 9044 CITY Alamo, STATE CA ZIP 94507 BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. I also certify that I have pr, rid-t#is- cation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinan e C _ s nd andard S to and Fe l laws. APPLICANT'S SIGNATURE Title: Owner / Pacific Excavators Date: 12-1-95 AUTHORIZATION TO RELEASE INFORMATION: In additio�to the abov , when applicable, I, the owner, operator or agent of same, of the property Located at the above site address here author' a the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my repr e tive. t Nature of Service Request: L0.Service Code Assigned to � � { \� Employee # I� Date x Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT CID Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By SUPV _/ / ACCT _/ / UNIT CLK _/ 1