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�J <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />M <br />SERVICE REQUEST <br />FACILITY ID # FAON3934 SERVICE RE EST # <br />Type of Business or Property Tank." 39-0002319450505184 d� �� ?/ <br />Federal Facility (879-G3u1) <br />OWNER 1 OPERATOR CHECK If BILLING ADDRESS <br />U.S. DOE/ UC LLNL, Beverlee Morales <br />FAC1UTY NAME LLNL - Site 300 <br />SITE ADDRESS <br />Corral Hollow Road Tracy 95376 <br />Street Numbor Direction <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />P.O. Box 808, L-695 <br />CITY Livermore <br />PHONE#1 EXT. APN # <br />(925) 422-7481 <br />PHONE #2 EXT. <br />Street Number ` Street Name <br />STATE CA Zip 94551 <br />LAND US£ APPLICATION # <br />NA <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK If BILLING ADDRESSLTI <br />U.S. DOE/UC LLNL, Shari Brigdon Exr. <br />BUSINESS NAME Lawrence Livermore National Laboratory (LLNL) (92# <br />5)423-7665 <br />FAX # <br />HOidE Or MAILING ADDRESS P.O. Box 808, L-627 (925) 422-2748 <br />CITY Livermore <br />STATE CA LP 94551 <br />1BU UAN G AcCX1g0 Y T.EiD(G!&MMIST: I, the undersigned property or business owner, operator or authorized agent of <br />same, 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 />A PIP LIICCAF31T9� �7tCR1.�TtU 2 : DATE. <br />PROPERTY / BUSINESS OWNER ❑ <br />OPERATOR 11'IAtiAGER ❑ __kOOTI3ER AIJTHDRIlED AGENT <br />❑ <br />If APPLICANT is not the BILLLVC P_A_& f , proof of authorization to sign is required Title T <br />�A TO jR1�1,1E 1Z IF lYI LTTO : When applicable, I, the owner or operator ofILUTt}te � /Ep <br />�OIR11 'DTII© A� IIIA 4PI1i A <br />located at the above site address, hereby authorize the release of any and all results, geotechnical data an <br />envlr <br />assessment information to the SAN JOAQUIN COUNTY BNVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the 004 <br />same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: NA C 1N COUNTY <br />SAN JOA tv1ENTAL <br />COMMENTS: ENVIRO NAE -NT <br />HEALTH D <br />NA <br />EMPLOYEE #: DATE: (s <br />ACCEPTED BY: <br />AsSIGNED To: ~ EMPLOYEE #: C DATE: <br />SERVICE CODE: <br />Date Service Completed (if already completed): <br />Fee Amount: <br />Amount Paid a J 0 Payment Date I S <br />/.� Received By: <br />Payment Type Invoice # Check # t Z 7-�-a <br />