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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> FACILITY NAME RMC Louestar, Inc. BILLING PARTY Y / Nd <br /> SITE ADDRESS 30350 South Tracy Blvd., <br /> CITY Tracy CA ZIP 95376 <br /> OWNER/OPERATOR RMC Lonestar, INC. BILLING PARTY <br /> DBA same PHONE #1 ( 510 ) 426 -22,79 <br /> ADDRESS P.O. Bog 5252 PHONE #2 ( ) <br /> CITY Pleasanton STATE CA ZIP 945616 <br /> FAPN # Land Use Application # <br /> 1E BOS Dist Location Code <br /> —t <br /> CONTRACTOR and/or Pacific Excavators <br /> SERVICE REQUESTOR BILLING PARTY Y / N <br /> DBA same PHONE #1 ( 510 ) 370 -8783 <br /> MAILING ADDRESS P.O. Bog 968 FAX # ( 510 ) 939 - 9044 <br /> CITY Alamo, STATE CA ZIP 94507 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have pr� h,i- plication and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinan e C s nd andard S t=Fe laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Owner / Pacific Egcavato Date: 12-1-95 <br /> AUTHORIZATION TO RELEASE INFORMATION: In additio to tJabovwhen applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address her athe release of any and all results, geotechnical data and/or <br /> environmental/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 /> Nature of Service Request: Service Code <br /> Assigned to Employee # Date / / <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> LUPV <br /> --./--/--]--ACCT _/ / UNIT CLK _/ / <br />