COMPLIANCE INFO_1995-2011 - Laserfiche WebLink

Home Browse Search

SERVICE REQUEST (EH 00 61) Revised 8/23/93 ,FACILITY ID # RECORD ID # INVOICE # =J FACILITY NAME RMC Lonestar, Inc. BILLING PARTY Y SITE ADDRESS 30350 South Tracy Blvd., CITY Tracy CA ZIP 95376 OWNER/OPERATOR RMC Lonestar, INC. BILLING PARTY DBA q-me PHONE #1 ( 510 ) 426 -2279 ADDRESS P.O. Box 5252 PHONE #2 ( ) CITY Pleasanton STATE CA ZIP 945616 APN # "IF Land Use Application # BOS Dist Location Code CONTRACTOR and/or Pacific Excavators SERVICE REQUESTOR BILLING PARTY Y / N DBA same PHONE #1 ( 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 re s-- Lcation_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 �t taus. APPLICANT'S SIGNATURE Title: Owner / Pacific Excavato 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 her 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 representative. Nature of Service Request: Service Code Assigned to Employee # Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By [ =LRENS _/ / SUPV _/ / ACCT _/ / UNIT CLK �/ /