Laserfiche WebLink
SITE MITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION THER LEAD AGENCY <br /> AGENCY CONTACT <br /> ITE NAME <br /> Lawrence Livermore National Laboratory (LLNL) PHONE <br /> DORESS Corral Hollow Road APN # <br /> ITY Tracy IP 95376 1 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME LLNL <br /> AILING ADDRESS 7000 East Avenue, P.O. Box 808 <br /> A <br /> (TY Livermore TATE CA IP 94550 <br /> ONTACT NAME C. Susi Jackson HONE (510) 423-6577 <br /> PROPERTY OWNER/OPERATOR <br /> AME I U.S. Government Department of Energy HONE (510) 273-4135 <br /> DORESS 1333 Broadway <br /> TATE CA IP 1 94612 <br /> ITY Oakland <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME C. Susi Jackson HONE 1 (510) 423-6577 <br /> DORESS 7000 East Avenue, P.O. Box 808 <br /> ITY Livermore TATE CA IP 94550 <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY <br /> AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION T( <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT 1S AVAILABLE AND AT THE SAME TIME IT I' <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> ADDITIONALLY, I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> PHS/EHD HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> 'AME C. Susi Jackson S# <br /> SIGNATURE <br /> OMPANY <br /> LLNL ITLE I Owner <br /> 89.007(IV)12/9OBILFRMI2 `�� <br />