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ERRONMENTAL HEALTH DIVISION 0 <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT <br /> IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK. <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. <br /> DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA Site # Project Contact&Telephone# <br /> F CA2890090002 C.Susi Jackson .(510)423-6577 <br /> A Facility Name I Phone# <br /> C Lawrence Livermore National Laboratory (LLNL), Site 3 (510)423-4881 <br /> I Mailing Address: 7000 East Avenue,P.O.Box 808,Livermore,CA 94550 <br /> L Site Address:Corral Hollow Road,south of Tracy,CA 94550 <br /> I Cross Street <br /> T located 15 miles east of Livermore on Corral Hollow Road (between Tesla Road and Highway 580) <br /> Y Owner/Operator.U.S.Government-Department of Energy Phone# <br /> University of California (510) 423-6577 <br /> Contractor Name Phone# <br /> C NA (LLNL, with contractor to perforrn labor only) <br /> O Contractor Address CA Lic # Class <br /> N <br /> T Insurer Work.Comp. # <br /> R Self-Insured <br /> A Fire District Permit # <br /> C LLNL, Site 300 Fire Department <br /> T Laboratory Name Phone# <br /> O California Laboratory Services (916) 638-7301 <br /> R Sampling Firm Phone# <br /> LLNL, Environmental Protection Depart ent (510) 423-4012 <br /> Tank ID# Tank Size Chemicals Stored Currentiv/Previously Date UST Installed <br /> 39-1jMs-1D1U1) 1,000 gallons Diesel fuel 1960 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P Approved Approved with Condition(s) Disapproved <br /> L (See Attachm t with Conditions) <br /> A � <br /> N Plan Reviewers Name�l<^ Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACC DANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> SPATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNS <br /> OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF <br /> THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR <br /> SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF <br /> THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S <br /> SIGNATURE:- ----------TITLE_rro _ C_ DATES=S—q -------- <br /> EH 23 046(REV 7/10/92) <br /> CLOSURE PLAN: 834-DIUI <br />