Laserfiche WebLink
01/05/04 13:00 FAX 925 422 2748 EPD / WGMG_-- IM001 <br />—--------- -- <br />- No d Pages J Todayb DaMI ~- ..�, i <br />Fax Note 7672 <br />... <br />"..LLN._ __..... <br />Ta 5treXa ..5hl h . I <br />., FIIXW _.._,.. <br />1,4 93 <br />tFax # �Ibg 3 3 !1 _-.!-it��'.-.`lam?. _ .. ,'fd'.75�8'...... 'T .... _rr'._._. <br />Slorginal oitpoNum ❑Destray . car for pki�up <br />I <br />Rearm El <br />rVjt 4,'47� <br />.,c^Wr_ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />__TFACILITY ID # FA0003934 SERVICE <br />Type of Business or Property Tank9 39-0002319450505184 <br />Federal Facility (879-G3U1) �0 <br />OWNER / OPERATOR <br />U.S. DOE/ UC LLNL, Beverlee Morales <br />FACItm NAME LLNL - Site 300 <br />SITE ADDRESS <br />Corral Hollow Road I Tracy <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />P.O. Box 808, L-695 <br />CITY Livermore <br />PH0NE#1 - -- <br />(925) 422-7481 <br />PHONE #2 <br />CONTRACTOR / SERVICE <br />REQUESTOR <br />U.S. DOE/UC LLNL, Shari Bri don <br />BUSINESS NAME Lawrence Livermore National Laboratory (LLNL) <br />HOME or MAILING ADDRESS P.O. Box 808, L-627 <br />rm <br />Livermore <br />STATE CA 75P 94551 <br />LAND USE APPLICATION # <br />NA <br />BOS DISTRICT LocAr <br />?UESTOR <br />CHECK U BBLII <br />PHONE # <br />(925) 423-7665 <br />FAX # <br />(925) 422-2748 <br />STATE CA 75P 94551 <br />95376 <br />CODE <br />ronv n ,rwm AmiKRt®�3r11,J&MgIEtYllia T: I, the undersigned property or business owner, operator or authorized agent of <br />same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMEN 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. ® C <br />AIPIPII ackN9f'ffi �IIciaF1A1CNA2L: ��, �F i1Jn DATE: /'/5J04 <br />13R AUTHORTxED AGENT <br />PROPERTY! BUSINESS OWNER <br />OPERATOR I MANAGER13 Jam, v,HE <br />proof <br />.i Title NT <br />If APPLICANT is not the R/LLZY PAS o authorization to sign is required , v G� <br />® : When applicable, I, the owner or operator lv tip e <br />located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or envir <br />assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the �ooA <br />`t <br />same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: NA <br />COMMENTS: <br />NA <br />ACCEPTED BY: <br />ASSIGNEDTO: <br />Date Service Service Completed (if already completed): <br />already completed):11, <br />1 <br />Fee Amount: Amount Pald <br />Payment Type <br />JOAO IN COUNT'S <br />SA <br />MENTAL <br />EN�IApO PARTMENT <br />HEALTH <br />EMPLOYEE #: DATE: L S ,(f <br />EMPLOYEE #: 2 DATE: r _r/Q <br />SERVICE CODE: IE: <br />l p Payment Date / s <br />Check # �-�-a Received By: iJ <br />