Laserfiche WebLink
SAN JOAQ#COUNTY ENVIRONMENTAL HEALTHREPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Government 313 SR M <br /> OWNER/OPERATOR <br /> Lawrence Livermore National Laboratoory CHECK if BILLING ADDRESS <br /> FACILITY NAME Site 300 <br /> SITE ADDRESS <br /> Street Number Direction Corral Hollows&A1e Tracy city95Z p Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( )925-423-6626 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Kathleen Henshaw CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Central Petroleum Maintenance 925-462-4060 <br /> HOME or MAILING ADDRESS FAx# 925-462-8352 <br /> 176 Wyoming Street ( ) <br /> CITY Pleasanton CA 94566 STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> 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 /> APPLICANT'S SIGNATURE: � �� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0 1 00 Irete <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at 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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 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: us r 12er, /T <br /> COMMENTS: <br /> SPS Jo a r1ME <br /> H <br /> ACCEPTED BY: EMPLOYEE#: 0Q5-�P DATE: <br /> ASSIGNED TO: EMPLOYEE#: Cr6 DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 90 P 1 E: Z3�0 <br /> Fee Amount: (p0 dV Amount Paid 3 .B C) Payment Date 19— if <br /> Payment Type Invoice# Check# Fieceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />