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SAN JOAQU0OUNTY ENVIRONMENTAL HEALTIWPARTMENT <br /> SERVICiE. REQUEST <br /> Type of Business or Property FACILITY ID# FA0003934 SERVICE REQUEST# <br /> Research and Development - Federal Facility Tank#39-0002319450505184 / <br /> (879-G3U1) l <br /> OWNER/OPERATOR <br /> U.S. DOE/ UC LLNL, Mishell Pendleton CHECK If BILLING ADDRESS❑ <br /> FACIuTY NAME LLNL-Site 300 <br /> SITE ADDRESS Corral Hollow Road Tracy 95376 <br /> Street Number I Dlreetlm, Street Name CKY Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> P.O.Box 808, L-695 street Number Serest Name <br /> CITY Livermore STATE CA ZIP 94551 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (925) 422-7482 NA <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> U.S. DOE/UC LLNL, Shari Bri don CHECK If BILLING ADDRESS <br /> BUSINESS NAME Lawrence Livermore National Laboratory (LLNL) PHONE# En. <br /> (925) 423-7665 <br /> HOME or MAILING ADDRESS P.O.Box 808,L-627 FAX# <br /> (925) 422-2748 <br /> CITY Livermore STATE CA ZIP 94551 <br /> IBUILILU14G A(CII;KOWILIEItD(C16F1IIIEN'T: I, the undersigned-property or business owner, operator or authorized agent of <br /> sante,acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this <br /> project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws <br /> AIPIP111CANT's �IIc�IYA7i'UIRIE: `-� .G-- DATE: -o2`DS <br /> PROPERTY/BusiNEss OWNER 13 OPERA R/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLiCANT is not tT3eBILL1NGPARTY,proof of authorization to sign is required Title <br /> AU TEDIP UZA7 UGH 1170 RIEII.3ASIE UNYOINATUON: When applicable, I, the owner or operator of the property <br /> located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site <br /> assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the <br /> same time it is provided to me or my representative. -� <br /> TYPE OF SERVICE REQUESTED: Modify spill bucket for UST 879-G3U1 to meet EVR requirements EIVE <br /> COMMENTS: "W"W <br /> �jiccv,'/��� <br /> �� 'Ge✓cSvIQI'"Y! ��UC�L�� SAN JOAQUIN COUNT <br /> ENVIRONME TNIENT <br /> HEp�TH DEPAR <br /> ACCEPTED BY: EMPLOYEE#: DATE: Q <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:,? <br /> Fee Amount: ff 2 I <br /> Amount Paid 1 Gj D Payment Date ff 0 S <br /> Payment Type ✓ Invoice# Check# 3/�S- Received By: �� <br />