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f <br /> 4 a <br /> FIED PROGRAM CONSOLIDATED FORM•TA <br /> ERGROUND STORAGE TANKS - FACI <br /> 879-G3U 1 WGMG05 115 <br /> One page per site Pae 1 of 1 <br /> TYPE OF ACTION <br /> !!! ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE aoo <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESSNAME(SameasFACILITYNAMEorDBA-DoingBusinessAs) 3 FACILITY ID# <br /> x Lawrence Livermore National Laboratory-Site 300 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' 402 <br /> Interstate 580 ❑1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS ❑1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403 ❑2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR [:14.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 <br /> 409. <br /> P.O. Box 808,L-633;7000 East Ave, L-633 <br />' CITY 410 STATE 411. <br /> i ZIP CODE 412 <br /> Livermore CA 94551-0808 <br /> PROPERTY OWNER TYPE ❑1.CORPORATION <br /> i ❑2.INDIVIDUAL [14.LOCAL AGENCY I DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP C35.COUNTY AGENCY ®7.FEDERAL AGENCY <br /> i III.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 an. STATE 41e ZIP CODE 419 <br /> Livermore CA 94551 0808 <br /> TANK OWNER TYPE ❑1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT [16,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 ® 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 [199.OTHER: <br /> ❑3.INSURANCE 0 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 notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER 0 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 42a. PHONE 425. <br /> C(•j. D (925)423-65-77 <br /> E OF APPLICANT(prin 428. TITLE OF APPLICANT 427, <br /> C. SUSI Jackson Division Leader,Operations and Regulatory Affairs Division, <br /> Environmental Protection Department <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use airy) 429 <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />