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Alk Ad& I'MI 4 <br /> W MW ptl4vit 1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM Ct�0TANKS <br /> UNDERGROUND STORAGE TANKS FACILIW WGMG03:144 <br /> (one page per site) Page I of 1 <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change,local use only.) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION FA _?q 3 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> Lawrence Livermore National Laboratory-S300 3 9 0 0 0 2 3 1 9 4 5 1 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* <br /> Interstate 580 ❑ 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ❑ 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR®6.OTHER 403 ❑3.PARTNERSHIP ®7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trust lands? operates the UST(This is the contact person for the tank records.) <br /> 5 at S300 404 ❑Yes ®No 405 William G.Hoppes 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> U. S.Government-Department of Ener 510 637-1809 <br /> MAILING OR STREET ADDRESS 409 <br /> 1301 Clay Street <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> Oakland CA 94612-5208 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ®7.FEDERAL AGENCY 413 <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME ala 1 PHONE 415 <br /> Lawrence Livermore National Laboratory 925 422-0158 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O. 808,L-627;7000 East Avenue,L-627 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Livermore I CA 1 94551-0808 <br /> TANK OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ®7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 ®Exempt Call 916 322-9669 if questions arise. 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑ 1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ®6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑1.FACILITY ❑2.PROPERTY OWNER ®3.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification-I gertify that the information provided herein is true and accurate to the best of my knowledge. <br /> 7 <br /> SIGNATU OFA I AN DATE 424 PHONE 425 <br /> 10/2/2003 (925)422-0158 <br /> NAME OF T int) 426 TITLE OF APPLICANT 427 <br /> William .Hoppes Group Leader,Water Guidance and Monitoring Group, <br /> Environmental Protection Department <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> 871-DIU2,882-DIUI <br /> UPCF(1/99 revised) Formerly SWRCB Form A <br />