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VERGROUND <br /> ED PROGRAM CONSOLIDATED FORM-TA <br /> STORAGE TANKS- FACIL i U01w\'01,_ 1 B <br /> 679-G3 GMG05: 15 <br /> One a e er site Pagel of 1 <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sam asFACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> 1. <br /> Lawrence Livermore National Laboratory-Site 300 <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE El4.LOCAL AGENCY/DISTRICT* 402 <br /> Interstate 580 ❑1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ❑1.GAS STATION Ll 3. AR ❑ .COMMERCIAL 403. [:12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR ®6.OTHER ❑3.PARTNERSHIP ®7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation or 405. *If owner of UST is a public agency:name of supervisor of division,section or office which 406. <br /> REMAINING AT SITE trust lands? operates the UST. (This is the contact person for the tank records.) <br /> 3 at Site 300 ❑Yes ®No C. Susi Jackson <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> U.S. Government-Department of Ener 925 422-2572 <br /> MAILING OR STREET ADDRESS 409. <br /> P.O. Box 808,L-633;7000 East Ave, L-633 <br /> CITY 410. 1 STATE 411• ZIP CODE 412. <br /> Livermore CA 94551-0808 <br /> PROPERTY OWNER TYPE ❑1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ®7.FEDERAL AGENCY <br /> 111.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Lawrence Livermore National Laboratory 925 423-6577 <br /> MAILING OR STREET ADDRESS 416. <br /> P.O. Box 808,L-633;7000 East Ave, L-633 <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Livermore CA 94551-0808 <br /> TANK OWNER TYPE ❑1.CORPORATION [12.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP [:15.COUNTY AGENCY ®7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44 1 1 IM Exempt Call 916 322-9669 if questions arise 421. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE 59 6.EXEMPTION ❑9.STATE FUND&CD <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 notificalions and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the inform tion provided herein is true and accurate to the best of my knowledge. <br /> SIGN OF PPLICANT DATE 424. PHONE 425. <br /> cf•�•0 � (925)423-6577 <br /> RAM OF APPLICANT(prin 426. TITLE OF APPLICANT 427. <br /> C. Susi Jackson Division Leader,Operations and Regulatory Affairs Division, <br /> Environmental Protection Department <br /> STATE UST FACILITY NUMBER(Agencyuse only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />