Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> Government, P-F .:: <br /> 251-140-05 <br /> OWNER/OPERATOR <br /> Department of Energy,Lawrence Livermore National Lab-C/O Ada Chan(Site Rep) CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Department of Energy,Lawrence Livermore National Lab <br /> SITE ADDRESS <br /> 15999 W Corr�i��L%,j Rd. Tracy Iy 953co le <br /> Street Number Direction ee <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street NumberF Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CEL(C/O Alex Lim) CHECK i1 BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Consolidated Engineering Laboratories(CEL) 415 272-8251 <br /> HOME Or MAILING ADDRESS FAX# <br /> 2001 Crow Canyon Road, Suite 100 ( ) <br /> CITY San Ramon STATE CA ZIP 94583 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agenp, �c, �"V <br /> acknowledge that all site and/or project specific ENVIRONMENTAL.I-IEALIII DEPARINIENI'hourly charges associated with this I I <br /> I <br /> or activity will be billed to me or my business as identified on this form. V�� <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with �N.J(IAfJJN? <br /> COUNTY Ordinance C'oiles,SlanthoY/s,STA FF and FI;m:RAL Iaws. jO <br /> FIyV/ o IN C <br /> APPLICANT'S SIGNATURE: �� D:�'rt:: �I I z ���CTyoF��t ji/rY <br /> I'uorr:ari/Brsl.rssUNesl•at❑ OPt:R:+,T'ota/NInu:u;a•.R ❑ OTln:uAt 1110lclzt:oAct:Nr13- Prn�er.7L E�trne�-r <br /> l/.II'I'l.v..t.v1 is not the B//,1, RT),prop/of(tit th orization to sign is reyrrired Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located al the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN Jt)AQUIN COIJN"rl' ENVIRONMENTAL.HFALI'll DEPARTMI N r as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ` <br /> COMMENTS: <br /> Soil Suitability Study and Nitrate Loading Study review <br /> F�s� Z�_RhtL P_r*uJC5 to Cot ik N 153 e C.L&L-&-ti v <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Compl ted (if already completed): SERVICE CODE: PIE:LI <br /> a <br /> Fee Amount: Amount Pal DD•0z) Payment ate 7 S <br /> Payment Type Invoice# Check# �lO Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />